During this live webinar, Dr. Neely will review the evaluation and management of common pediatric glaucomas. Instruction will include surgical videos and discussion of surgical techniques. Live audience questions are encouraged but participants may also submit questions or patient cases for discussion in advance by entering those in the Questions box below.
Lecturer: Dr. Daniel Neely, Pediatric Ophthalmologist and Professor of Ophthalmology | Indiana University School of Medicine, Indianapolis, USA
DR NEELY: Well, happy pandemic Monday to everybody, and welcome to the Cybersight broadcast studios live in my kitchen, as we’re still on partial lockdown. I hope you’re all doing well. Here in the United States, we’re just now kind of getting back to business a little bit. Our surgery schedules and clinic schedules are about 50% now. I’m hoping within the next month, by the month of June, we’re kind of getting back to regular schedules. Today we’re gonna talk about one of my favorite topics, which is pediatric glaucoma. A lot of this is gonna actually be talking about congenital glaucoma. I’ve been an Orbis volunteer for about 20 years now, and I think I’ve done more than 20 programs and operated in about 13 different countries. And what I can tell you is that the issue of pediatric glaucoma, and particularly congenital glaucoma, is universal. And we all struggle with the surgeries and treating these patients. It’s a difficult problem. Fortunately, the techniques are actually not that complicated, once someone demonstrates them to you, and the equipment requirements are not that intensive, so it is something that we can all easily learn to do. And we have a fellowship program here at my university in Indiana, and we’ve trained over 100 fellows in pediatric ophthalmology. And this is definitely one of the reasons why they come and train with us, is because we do a lot of glaucoma. Welcome to everybody. We now have over 500 people on this webinar. And what I would like to do — we’re gonna do quite a few videos today as well. So there will be some downtime, while we’re watching the videos, that I’ll be trolling through the chats, and I’ll take questions, and we’ll pause periodically to answer questions, so please do use the chat feature to submit your questions. This is probably gonna be all of an hour. If you can’t stay the whole time, of course it gets recorded, and we have the subtitles, and it will be posted live on Cybersight. I’ll also mention now and again at the end that all of this material that we’re doing today is also in the Cybersight courses. Within pediatric ophthalmology coursework, there is a module, module five, which is pediatric glaucoma. And you can also find it as a standalone course, underneath the pediatric ophthalmology section. And there’s a manual in there as well, and I’ll point that out again at the end, for those who join late. We’re now almost up to 600 people, so let’s get rolling. I’m going to first of all share my screen. We’ll be using the white board a little bit today, but I’m first going to go into the PowerPoint here, and let’s start with this. And again, pediatric glaucoma — a lot of emphasis on congenital glaucoma today. First poll question. Let’s kind of get the lay of the land here. What I would like to know, from the people that are on this webinar, in your practice, do you do any pediatric glaucoma, do you see a few cases of pediatric glaucoma, or do you see a lot of pediatric glaucoma? And so go ahead and answer the poll question now. And we’ll kind of see where we all are. For me, personally, cataracts and glaucoma and retinoblastoma and plastics used to be about 50% of my practice. It seems like as we’ve hired more partners, I do fewer cases of those, even though it’s still something I like to do. I still do several cases of pediatric glaucoma every month. All right. And the poll results. Here we go. We have — basically we’re mostly in the same boat. A few cases, which is typical. This is not — there’s some variability in how common congenital glaucoma is, depending on regions, and then the rest of the pediatric glaucomas depend frequently on how much cataract surgery you do, because aphakic and pseudophakic glaucoma is such a common issue. Probably 20% of those patients develop glaucoma. But when we talk about pediatric glaucoma, really mostly what comes to mind is congenital glaucoma, even though that’s only about 25% of total pediatric glaucoma cases. That’s really kind of what jumps into our mind, and what we think of. And this is a pretty typical example here. When they get picked up relatively early, at least. So what is congenital glaucoma? Of course, it’s the dysplasia of the chamber angle. And I’ll show you some really good images of what that angle looks like. And these children by definition have no other problems. It’s an isolated thing limited to the trabecular meshwork. It’s not part of a syndrome or anything else. And here’s that gonioscopy view in this blue iris. You can really see how scalloped this whole chamber — I’m sorry, this whole iris insertion is. So what are the hallmarks? We tend to have the scalloping. Irregular — almost looks like posterior synechiae, or peripheral synechiae, but they’re not. There tends to be an anterior iris insertion. So the iris insertion probably should actually be back here a little bit. And you’ll see when we do goniotomies, this is just in front of that area, where we’re gonna be cutting across, where all this stuff is pulled forward. Oops. Let me go back. We’re still talking about this. It’s typical — you’ll see some blood vessels out here. What you don’t see — we always talk about gonioscopy and looking at pigmented trabecular meshwork bands — in these young kids, they haven’t had much time to build up pigment, so the banding of the trabecular meshwork is usually pretty indistinct, like what you see here. You can see it a little bit, but it’s not what we classically see in the textbooks. Pretty typical gonioscopy view here. And then we have all the other glaucomas. These are kids that have other problems. Cataracts, aphakia, this kid, Sturge-Weber, uveitis is a big one, we see a lot of that, anterior segment dysgenesis, because other parts of the eye have abnormalities. It’s a secondary glaucoma. And the list goes on and on. There are lots of causes. Trauma. With these other glaucomas that we have to deal with. Aniridia is another one. If I have to pick the two worst ones for me, it’s Sturge-Weber and aniridia. They’re just really tough to treat, and that’s always a frustrating problem. Congenital glaucoma, the classic triad we talked about. And my cat is joining us. Here we are at home. So she may walk across the screen here in a minute. We’ll see. The classic triad. We have the epiphora or tearing, photophobia, light sensitivity, and squinting or blepharospasm from that discomfort. One of the things I’ve found recently with our restrictions — for about a month, we were only seeing emergency patients, so we were doing a lot of telemedicine with patients, and one of the big things we wanted to be able to do was look at infants who had tear duct obstructions, and talk to parents and see what the infant looked like, to make sure we weren’t missing cases of congenital glaucoma. Just the remark here — tear duct obstructions do not typically have photophobia. If someone has photophobia and tearing, that needs to be looked at. You can see this kid has glaucoma. But it’s not obvious. A lot of times, people think they just have these big lovely eyes, but it’s a little bit more than that. A big part of managing pediatric glaucoma is doing an examination under anesthesia. Because a lot of these children are not able to cooperate. Or we just need more information than what we can get in the office. So slit lamp examination, of course, looking at the anterior chamber, gonioscopy with the slit lamp you can do. And then also, Haab’s striae. We frequently track the horizontal corneal diameter. Why the horizontal instead of the vertical? Simply because the vertical white to white, especially superiorly, is pretty variable, as to how much conjunctiva, sclera, comes onto the cornea. Whereas horizontally, the margins are much more defined. So we’re tracking that horizontal corneal diameter. Now, for that to be useful, you need to know what normals are. And in a newborn infant, a normal corneal diameter is about 9.5 to 10.5 millimeters. Now, when they’re unilateral like this kid is, you can clearly tell that one eye is bigger than the other, but when the disease is bilateral, symmetric, it can be more difficult to tell. So being aware of this is important. And again, normal adults can be 12, 12.5 millimeters, white to white. And these glaucomatous kids, it’s not uncommon to see 13, 14, and I’ve even seen kids that are up around 17 millimeters, when they really get advanced. But of course, a lot of other things change when that happens too. Haab’s striae. What are these? These are simply the Descemet’s membrane get stretched so much that it can’t stretch anymore and it splits, and it gives us that railroad track appearance. A little bit tough to tell in this photograph, but you can see one scrolled edge of Descemet’s along here, and the second one is along here. And when that first happens and the pressures are up, of course we’ll get corneal edema. Once you get the disease process under control, then these Haab’s striae tend to be quite transparent, and in themselves, don’t usually cause a lot of visual disruption. It’s usually the amblyopia. When does this happen? Well usually once you get corneas above 13 millimeters, is when Descemet’s membrane starts to kind of give out, and we get these. And then of course corneal enlargement becomes corneal edema. And when it really gets advanced, the child on the screen left is a pretty typical example of what happens when we don’t treat congenital glaucoma. And again, that’s why it’s one of my favorite things to teach, is because if you have the basic techniques, you can avoid that from happening. There’s no way you can help that child on screen left. It’s just too late. So we need to intervene before we get to that stage. The child on the right has central corneal edema. This is actually an anterior segment dysgenesis and not congenital glaucoma, but of course the two can be associated. This happens to be a bilateral case of Peters. Well, that tendency for the cornea to get large, and for the eye to be, if you will, stretchy, because the collagen is immature, that actually helps us in some ways. Because the eye is getting larger, and the optic nerve cup and the optic nerve ring is expanding as well, I think that protects the nerve axons from being just damaged, like we see in high pressures, in adults. So there’s a little bit — it buys us a little bit of time. And some of this may be reversible. You don’t tend to see buphthalmos reversed too much. You can see a little bit of shrinking of corneal diameters, but we definitely see optic nerve cups regress. And I’ll show you a couple pictures here in a second. The younger they are, of course, the more likely we’ll see this regression. I don’t think you’re gonna see it much — much regression once the kids are above age 4 or 5. Which is also true — you don’t tend to see buphthalmos developing much after that age, and maybe even younger. So here’s an example from my practice. On the screen left, this is a hazy view of an optic nerve that I took during exam under anesthesia before surgery. I would just estimate that cup to disc ratio to be at least 0.6 vertically, and at least 0.5 horizontally, maybe larger. And then after having angle surgery, and we have a clear cornea now, and you can see that nerve is about a 0.4 in both directions. So that cupping has regressed. And so it’s an indication that early intervention, of course, can be quite beneficial. People pay a lot of attention to the elevated pressures. And I’ve got to tell you, when I make decisions about surgery, it almost might be the least important thing I look at. Yes, the pressures can be dramatically high. You can see pressures that are 40. But it’s not too uncommon that I operate on infants with pressures under 23, which we would consider normal for an adult. And the reason is: A normal pressure in an infant is more like 10 or less than 20. And so the symmetry is also important here. If you see one eye is 10 and the other eye is 22, well, 10 is probably the normal pressure for that baby. And a 22 is two times normal. So when I’m making decisions about surgery, I’m more likely to make a decision based on symmetry of the intraocular pressures, the pressure to some degree, how many medicines they’re on, also axial length, looking at changes in axial length over time, and symmetry between the two eyes, as well as white to white diameter, and don’t forget refraction. Because if the refraction is changing a lot, and you’re seeing increased myopia, that’s because the pressure is too high, and that eye is getting longer, so you’re getting axial elongation. So if you don’t have an A-scan, that’s okay. You can just follow the refraction to some degree. And then of course, changes to the optic nerve, although, again, frankly that oftentimes is very tough to track, and it’s very subjective, and it’s a hazy view, and by the time you see changes in the nerve, you may actually be losing the game at that point. Taking pressures. Lots of different ways. And what do you do? You use whatever you have. You know? If you have the ability to use tonometry, like these automated tonometers, do I think that’s ideal? Absolutely. Okay? It’s reproducible. They tend to be relatively accurate. And easy to use. The Tonopen on the left can be used in any position. The iCare on the right — some models can be used only vertically. Some models can be used when the child is laying down. And then even if you have the vertical model, people can turn their head and get pressure readings. So you use what you have. If you have a Schiotz, use a Schiotz. Again, this element of the exam under anesthesia is probably the least — almost the least important to me. But in the clinic in particular, it’s really helpful to kind of see what’s going on, when they’re not under anesthesia, and monitor these pressures. We even have some patients who — families that are willing to invest the money. They’ll buy their own tonometers. I think sometimes that creates more problems, though. So just to give you some reference, how accurate are these things? We’ve studied it, and I’ll tell you that basically the Tono-Pen and the Goldmann tonometer came out about the same. These are slightly older kids. Not so much infants. Because we wanted to be able to do Goldmann. So the age range was 6 to 13. Some of those couldn’t do Goldmann applanation, of course. I don’t know that I could do it on myself. And we excluded those that had significant abnormalities. Let’s look at the results here. So Goldmann here on the right — we would consider this to be the gold standard. And the average pressure was 16. Right and left eyes. Tono-Pen. Almost the exact same as the Goldmann. So I really like to use the Tono-Pen for that reason. However, it does require anesthesia. So in our clinic, we frequently use the iCare. And I don’t mind screening people with the iCare, but there is a bit of a significant difference in the pressure readings. It tends to be about 3 millimeters of mercury higher in general. So if we’re screening patients with the iCare because it doesn’t require anesthesia, and you can get readings easier on some kids, if that pressure is high, I do ask that the technicians recheck with Tono-Pen or Goldmann. So just keep that in mind. iCare is great. It does tend to read a little bit high. Okay. So I’m going to pause for a second. And I’m just gonna open up some of the questions here. And drink my coffee. Okay. So some of the questions here. If a suspicious cup was observed but without increase in intraocular pressure, does this child need follow-up? Is it possible to have normal pressure pediatric glaucoma is the pressure here. So normal pressure glaucoma — yeah, I don’t know that we know exactly how common that is in the pediatric population. But I will tell you that having done this for 23 years, I think it’s distinctly very, very, very uncommon. We see it in adults, and we have to be aware of it. If I’ve seen any cases of normal tension glaucoma in children, it’s less than 5 in 20 years, for sure. At least that we knew of. Okay? So most of the time, what I find is I get children referred to me with suspicious cups, and what I find is that they just have physiologic cupping. The cups are symmetric on both sides. The rims are symmetric. In appearance. And if you can check visual fields, you check visual fields. If you can get an OCT, you get OCT, if you can get photographs, you get photographs. Let me give you one tip, though. A lot of times what I find is that the most helpful thing is to look at the parent. Just take a direct ophthalmoscope. Look at the parent’s eyes. And a lot of times, you’ll find that the mother or father has optic nerves that look exactly the same. Okay? And then the next question is about eye drops, which is our next subject, so I’m just going to dig into that section. And I promise to get through all these questions, even if we stay on the end and I have to take them. I will get through all these questions. Because I like the fact that you guys are asking questions. And I see some questions about surgery. Here’s one that has to do with the examination. So let’s touch on this now. Can we diagnose pediatric glaucoma just with the diameter of the cornea and the high intraocular pressure? Yeah. I think to some degree. If someone comes in — you can of course have megalocornea. Right? You can just have a big cornea and no abnormality. But if you have a big cornea and an elevated or suspicious intraocular pressure, I think definitely this person is a glaucoma suspect. And I probably would have very high suspicion — and usually just give them the diagnosis — of pediatric glaucoma. And keep in mind, you can’t have juvenile glaucoma. That’s not something we’ve talked about. Juvenile glaucoma definitely happens. Not as common as these other younger child glaucomas, but you can see glaucoma in teenagers. Juvenile onset glaucoma is definitely more common than normal tension glaucoma. I’ll see a surgery question. We’ll get to that. Another surgery question. Here’s a question about what we’ve been talking about — any chance of buphthalmos being reversible, like the optic nerve head being reversible. Yes, a little bit. You can see a little bit of shrinkage of the horizontal white to white. Maybe. Half a millimeter can regress. You definitely can see the axial length and the refraction regress. That seems to happen more easily than the corneal diameter regressing. So yes. A little bit. But if you have an eye that has a horizontal diameter, 14 millimeters, it’s not gonna go back to being 12 millimeters. These eyes always look larger, even once you get the pressure reversible. There was a question about: What’s the reason for the reversible cupping? I think it’s just that scleral ring around the optic nerve. As the eye is enlarging, that ring enlarges, and just lets the nerve spread out in the area that it’s covering. And then as the pressure comes down, that scleral ring comes down, and the nerve size kind of collapses. So I don’t think it’s a regeneration of nerve cells or anything like that. It’s just simply that the size of the scleral ring around the nerve expands and then comes back down. There’s a question on the role of central corneal thickness in pediatric glaucoma. This gets a lot of questions. And at first, I was recording it all the time, and we were fudging our pressure numbers a little bit, based on the central corneal thickness, but I think as time has gone on, the glaucoma specialists feel that central corneal thickness has less and less impact on the pressure readings. I still monitor it, because sometimes you can find a cornea that’s super thick. Especially if it’s scarred. And you just know if you have a super thick cornea, that your pressure readings might be a little suspicious. So we do pay attention to it. But I don’t make huge adjustments for it. All right, here was a question about the iCare measurements being an overestimate, again. About 3 millimeters higher than Goldmann, or Tono-Pen. And someone else agreeing that the numbers are the least important parameter. Right? We’ve got to pay attention to what’s going on with the eye. Why are the numbers not so important? Especially the pressure numbers? Well, some eyes can tolerate high pressures. Some eyes can’t. If you see changes in the eye, that eye is not tolerating whatever the number is, on the tonometer. So pay attention to what the eye is doing. A little less attention to what the number on the machine is. Here’s a question about prostaglandins. That’s our next topic. Medications. Another question about iCare versus Tono-Pen. I think we’ve covered that. Does the Tono-Pen still need anesthesia? Yeah, pretty much. You have to tap it on the cornea so much to get readings that most people can’t tolerate that. So we routinely give everyone anesthesia, topical drops, with the Tono-Pen and not the iCare. Okay. So here’s something relative to EUAs — what’s the best anesthetic agent, since most agents lower the IOP? True. Most agents other than succinylcholine will lower the IOP. What do we do? We just get the pressures right away. When we’re doing an EUA, we go in the room, when the patient does, as the anesthesiologist starts to mask them down, as soon as they seem relaxed, we’ll kind of reach around before they do the airway, and we’ll measure our pressures, and then once the airway is secure, I will measure them again, because I find that sometimes early under the anesthesia, while the gases haven’t lowered the pressure yet, the child is still tense, or straining, and the pressures are actually higher than normal. So I measure them before the intubation and after the intubation, but if someone’s under anesthesia for 20 minutes, to give you an example now — because I just did some pediatric glaucoma last week — and we have to be out of the room for 15 minutes after intubation, because of concerns of COVID virus and aerosols. So we can get a pressure during the mask, but then we’re out of the room for 15 minutes, until we can get the postintubation pressure, and the pressure comes down some. Say it’s 22 during the induction. After 15 minutes of anesthesia, we were getting something like 18. So it comes down, but it’s not gonna come down 10 points. It’s not gonna come down 20 points. It might come down 4 or 5 points. That’s a good question and that’s been a good illustration of that. Okay. So some more medication questions. Surgery questions. Anesthesia questions. We covered that. Here’s a question. Can primary congenital glaucoma be unilateral? Absolutely. About a third of the cases or so. Right? And then tube shunt question. We’ll get to that. What do you consider as a normal intraocular pressure in children from birth to 5 years? Lower than an adult. So I would say anywhere — I think the numbers I threw out for infants is probably relatively accurate for young children. Anywhere from 10 to 20 is probably relatively normal. But I don’t get — and here’s a reason for corneal enlargement. Again, you think — why do young kids’ eyes expand? It just has to do with their collagen structure. Right? Kids are more flexible. Their bones are more flexible. Partly because of the collagen. Partly because they’re just not as ossified. But just think how incredibly flexible young children are. It’s because of the collagen structure at that age. And that’s why the eye will enlarge, and as their collagen matures, they get less flexible, and the eye is less likely to get buphthalmic. Question about — if you get cup asymmetry in the clinic, what do you do? Well, of course, that can depend on a lot of things. But if you have asymmetry of the cups, then I definitely follow that person closely. At least every six months, until I’m comfortable that they do or don’t have glaucoma. Here’s someone who uses Perkins tonometer. Perkins of course is like a Goldmann tonometer but in a handheld unit. I think that’s great. I find them difficult to use. Just me. I’m not very good at it. That’s the only negative about it. I think it’s great. Question about measuring pressure with central corneal thickness, anterior segment dysgenesis. Good question. It applies to the office and EUA. If someone has corneal scarring, whether in the middle or the periphery, don’t take the pressure where the scar is. If you take the pressure over an opacity or a scar, especially with the Tono-Pen or iCare, it is going to read very high, because that cornea is very stiff right there. I always try to go find some clear cornea. Even if it’s not in the middle. You can even do tonometry on the sclera. Is it as accurate? No, but you get a ballpark number. Another question about eye drops and lasers. We’re getting there. When you check intraocular pressure under general anesthesia, what is a cutoff value above which you consider to be abnormal? I don’t think I have one. Because there are just too many factors going on. We record it, I look at it, but I would never say that for any — you could never give a cutoff value. I’m never gonna say 22 is the number or I’m never gonna say 26 is the number. I have kids running around with pressures that are in the high 20s, and I don’t operate on them, because they seem to be doing okay. And I have kids with pressures under 20 that I do operate on. So just like in adults, I wouldn’t say that there is an absolute. You’ve got to see what the eye is doing, and then make your decision. And that’s not always the most comfortable answer, but I think that’s kind of what you pick up with time and experience. All right. We’ve got lots of questions rolling in. So I’m gonna get back to the lecture a little bit, so we can cover some of our — at least the early surgical topics. We’ve got 63 questions in the queue. I think that’s fantastic. But let me keep spacing them out a little bit. I’ll close the questions here for a minute, and then go back to the — let’s talk about the medications. And then I’ll take some more questions and we’ll talk about the surgeries. I have a suspicion that we won’t get through the entire lecture, even in an hour and a half. Because I like these questions that we’re doing. But if I can get through at least angle surgeries, I’ll be happy with that. The rest of it — tube shunts and trabeculectomies — we can cover at another date, if we want to do that. I’m really happy about you guys submitting all these questions. I just think that’s beautiful. This was kind of an eye-opener to me, because I just updated this lecture from a couple years ago. And even I learned a few things, getting ready for this. Let me give you some frame of reference. We have a lot of options now. I didn’t realize how many there were. When I was a resident, about 22 or so years ago, 1993 through ’97, I was a resident, and you see the ones that are highlighted here in yellow? Those are the only medicines we had, and that was not that long ago. I’m not too old. A little gray, but we had beta blockers, we had pilocarpine, still using a lot of that then. Had oral Diamox, and Apraclonidine had just recently been approved for postlaser use. Once in a while we would use that in patients. Look how limited those options were. You compare that to what we’re gonna talk about in the next few minutes, and it’s incredible. There were questions on what I usually use in young children. For a long time, if I had a kid with congenital glaucoma, and I’m just trying to buy time to get them in an operating room, these beta one selective units would be my first choice. Trade name is betaxolol, Betoptic in the US, 0.25 concentration. It’s beta 1 selective. As far as I know, the only one that’s beta 1 selective. That means it’s less likely to have pulmonary effects. So that’s why that would be my preference in a young infant. But I think it’s very tough to get. And in general, I don’t mind using beta blockers in young kids. I do have parents do punctal occlusion. I do try to use the lowest concentration available. And basically these are just temporizing, until you can get in the operating room. Oral Diamox is also pretty safe with infants, because it’s all weight-based. Pilocarpine I almost never use in children. Even older children. And it’s because they get such accommodative spasm, brow ache, all those kind of fun things. Still a useful drug, and I’ll use it very rarely. But not too commonly. The alpha agonists, brimonidine, that’s a big one we’re gonna touch on here in just a second. Because this is probably the one drug that’s potentially a problem. It works well. I use it in older kids. I have problems with the eye being irritated and red. The carbonic anhydrase inhibitors, we’ll talk about those in a minute, because I really like those. The prostaglandin analogs — so there are at least four different varieties of these now. I’ll tell you in general I have not been super impressed with their efficacy in children. Maybe older children, teenagers, they’re a little more useful, but in young children, I really have been disappointed in them, although I really like the appeal of them, because they’re all usually once a day. But kind of disappointing to me. I usually use them as a third line therapy, or maybe as a primary therapy in an older child. So these — I’ll tell you right now, the next two that we’re gonna talk about are relatively new, within the last two or three years, and I haven’t used them. I have some patients who have been placed on them by adult glaucoma specialists, and they have been effective, and that’s all I can tell you firsthand. This new class, the Rho kinase or ROCK inhibitors, new class of drugs which are improving aqueous outflow… I think the mechanism is still a little bit in discussion. But basically there seems to be some contraction or microcellular changes that happen in the trabecular meshwork. And these can help with aqueous outflow. Again, keep that in mind. Whether they have broad application to pediatric use I don’t know yet. Keep paying attention to that. The other one, Vyzulta — I wasn’t aware of this one either. Or at least I hadn’t used it. Nitric oxide. This drop, when placed in the eye, releases latanoprost, a prostaglandin analog, and also nitric oxide, and it’s thought to relax the trabecular meshwork. So both of these drops are helping outflow. Most of our other drops are helping the decreased production of aqueous, but these two are helping outflow. By that very nature, they probably are not gonna help a whole lot, if you have an abnormal angle, like in primary congenital glaucoma. So I see these as more being second or third line drugs in older kids, whose angles are a little more normal and not dysplastic. The combinations. I really like combinations in kids. Because a lot of times, we do need more than one medication in children, and they seem to be pretty effective. A lot of these are synergistic. My personal go-to favorite is Cosopt, the timolol-dorzolamide. I find that to be very effective in children. It’s just twice daily. It burns. People don’t like that. But I have them keep it refrigerated, and the coldness seems to help negate the sting they feel from the pH. And then we have the other combinations. Some of these are not available in the United States. All these prostaglandin combinations are not currently available in the US, so I don’t have any experience with those. Really just the Cosopt and Combigan are the ones I’ve used personally. Simbrinza — I’ve heard some people speaking very highly of that. In the chat, if you have any personal experience with some of these combinations, or the two new ones that I mentioned, tell me. Tell me what it was. I would love to hear from you, and I can read that out and share it with the group. The two that I want to highlight again are this one, Betoptic, because it’s beta 1 selective. That would be my preferred drop in an infant, until I can get them to surgery. The one I want to warn you about is Alphagan-brimonidine. This is the only drop I’ve ever ever ever had issues with in young children. Before we knew about this, I was getting calls from some parents, saying that they would give the drop and the child would become so somnolent that they would be asleep for the next 8 hours. No one ever had any medical issues or ill effects, but they just had CNS depression and were tired. So I avoid this in general in children under five, or if they just have small children, if they’re not — because all this stuff is kind of weight-based, right? We give the same drop to a 20-pound kid you give to a 200-pound adult. That’s a bit of a dosing discrepancy. So punctal occlusion, if people can do it, is a good idea. If you can teach them, and simply avoiding brimonidine in younger kids. Older kids, I use it all the time. I think it’s great. I don’t have a problem with it. But you need to be aware that it has some CNS depression. Before we talk about surgery, let me go back to the questions for a second. We’re about 40 minutes in. Yeah, we’re definitely gonna be pressed to get through things. Skip on this for a minute. Let’s get back to the questions. All right. Let me find some that might be medicine-related here so far. For a prescription of topical Optimol — I assume it’s a beta blocker — should we give half dose of adult or the regular 0.5%? If you can get the lower dose and it’s a smaller child, I would give the lower dose. If it’s a larger child, or you just don’t have access to the lower dose, then I give the higher dose. I don’t know that it’s a huge difference. But I think it makes sense to give a smaller person a smaller dose. You all right. Which is the first drug for a child? For me, it’s probably gonna be a beta blocker, or a combination beta blocker/aqueous suppressant. Like Cosopt, again. Beta blocker and dorzolamide. For me, those are usually my most effective ones. Here’s an interesting question. Because this has come up. Your experience with repeated general anesthesia in kids with cognitive impairment. Yeah. So there’s a lot of attention about giving children repeated general anesthesias, and does this cause problems? There appears to be some evidence that multiple general anesthesias, especially in a short period of time, can cause some cognitive impairment. So I think — I don’t know that it changes what I do. I think we’re aware of it, and we try to factor that in. Just like we try to limit doing CT scans in children now. Right? It used to be pretty common that we would do CT scans in children. There’s evidence that that’s not the smartest thing to do. With the radiation exposure. And so now we’re more likely to do MRIs. But MRIs are harder to get. Some places don’t have them at all. And it requires anesthesia. So you always kind of have to weigh the pros and cons. Yes, try to avoid repeated general anesthesias. And yes, try to avoid CT scans, but sometimes you’ve got to do what you’ve got to do. Right? As in everything in medicine, there are no absolutes. And you’ve got to go with what’s practical. There was another question about anesthetic agents. I think we kind of touched on that. A question about OCT evaluation in children. Yeah, we use OCT. And especially following older kids. We don’t do a lot of intraoperative OCT or intra-OR. I’ve used it a few times. It has some cool pictures. I don’t know. I think it’s more useful in the older kids, when you can follow them over time, and they can do it in the office. Anything you can do — you know, photographs are just so subjective. So anything you can do to monitor that, I think, is quite useful. Oh, this is a great opportunity for me to plug a Cybersight feature. So the Cybersight consult feature has added artificial intelligence options. And one of those is to screen for diabetic retinopathy, and show you where blot hemorrhages are, and help grade the diabetic retinopathy. But another feature we now have is optic nerve head analysis. It’s mostly designed as a screening tool to pick up abnormalities, but it basically will show you the optic nerve and estimate the cup to disc ratio. For me, I’m kind of thinking about this as primitive OCT. Or just another way to objectively follow these optic nerves. So you can either submit your optic nerve photograph as a consult, to a mentor, or you can just do what we call AI-only, and just have the AI software grade your optic nerve. And I think that’s a pretty cool feature. You can look for a lot more AI stuff coming from us. We now have a full-time AI programmer, and it’s gonna be pretty cool to see what comes out. Tonometry with Goldmann appears difficult for some children. Yes, it absolutely is difficult for some children. It’s difficult for some adults. That’s why we all like the iCare and Tono-Pens. Okay. So we’re getting ready to talk about surgery. Here’s a question. How soon will you operate on primary congenital glaucoma in an infant? Well, how soon I operate for primary congenital glaucoma in an infant is almost right away. Now, we don’t do it same-day. It doesn’t have that urgency. But once we identify someone, once someone is referred to us from a pediatrician or another physician or optometrist, once we see them and suspect that they have primary congenital glaucoma, that child is gonna go to the operating room within a week, usually. So it doesn’t have to be that day. It doesn’t have to be the next day. We typically start them on some medications, and then we will get them in the operating room as soon as we can. So that means you’re operating on infants. Right? Just like congenital cataract surgery. You’re taking children that might be 4 weeks, 6 weeks, 8 weeks old, to the operating room. And whether or not you do that also depends on your anesthesia situation. Because one thing I know from working around the world is that pediatric anesthesia is a pretty variable bag out there. Some places are very skilled at taking care of young infants. And other places, it’s quite dangerous to take an infant to the operating room. We always have to take that into consideration. And it’s another reason why, if you are going to the operating room, if anesthesia is an issue, and you have bilateral glaucoma, you probably ought to do both sides at the same time. Now, where I practice, at a children’s hospital, the anesthesiologists are great. I usually don’t do bilateral surgery. But even in my institution, I could justify doing bilateral simultaneous surgery. And I think that’s one of the things we have to pay attention to. All right. Let’s talk about surgery a little bit. And then we’ll keep after these questions too. Another poll question first here. As we talk about surgery, let’s get a feel for what we all do, regarding pediatric glaucoma surgery. Which of the following most applies to you. One, I never do it, and I never will. I wouldn’t blame you for that choice. It can be frustrating sometimes. Two, I do not perform it, but I would like to. Right? We can teach this. It can be done. Three, I perform occasionally, but would like to get better. I think we would all like to improve. And four, I perform on a regular basis, and I’m very comfortable with it. You know, that’s where I am now. It is something that we learn over time. And I must say that my comfort level has improved over time. I used to like to only do goniotomies, because I couldn’t find Schlemm’s canal in trabeculotomies. But as I got better, I changed my practice. Our group here — a lot of people do not perform it but would like to. My international experience has shown me that’s a common request, and that’s why I do a lot of work for Orbis, because people would like to learn pediatric glaucoma and cataracts also. So that gets me out there. That all makes sense to me. So treatment options. I just mentioned a few of them. Goniotomy. Trabeculotomy. That differs from trabeculectomy. And now we have different kinds of trabeculotomy. We have traditional. And we have the new 360-degree internal and external options. Tube shunt implants. And cyclodestruction. Since we’re kind of focusing on congenital glaucoma so far, let’s talk about the first two. Because these are the ones that we can easily learn. The equipment is not a significant investment. And you can fix most kids with these two things. You can keep kids from going blind with about $100 worth of equipment and 30 minutes’ worth of training. I tell you, this is one of the most rewarding things that I get, when I go teach someone how to do a trabeculotomy, and that is a win right there. All right, let’s look at goniotomy first. First, another poll question, of course. All right. So if you are doing surgery, what do you usually do? What do you like? We all have preferences. Only goniotomies, because that’s all you know how to do, only trabeculectomies, because you don’t have a gonio lens, do you do both, depending on the situation? Do you do trabeculectomies, or tube shunts? I’ll tell you, I almost never do trabeculectomies anymore. I did them for a while early in my career in children. It was usually antimetabolites, and just had so many failures and difficulties. All right, so a lot of people of course do not do it. We have a small number of goniotomies. And small to medium numbers of trabeculotomy and goniotomy. That’s mostly what we’re gonna talk about. So that’s perfect. All right. Surgery for congenital glaucoma. Where is the problem in congenital glaucoma? It is the trabecular meshwork. The angle. That’s where we do our surgery. We need to open that angle up. So you have two primary types of interventions. Goniotomy and trabeculotomy. There are papers that will say they’re equally effective. Maybe. I can’t tell you that I know that, because I’ve used them in different populations. All right? You can’t do a goniotomy if the cornea is cloudy. So by definition, you’re going to be doing those in more mild cases of glaucoma. That may skew the effectiveness of goniotomy. Trabeculotomy — if you’re gonna learn one procedure, trabeculotomy is the one to learn. Because you can do it whether the cornea is cloudy or clear. It doesn’t matter. And it takes those two little trabeculotomes, and you’re in business. A little bit of practice finding Schlemm’s canal, and you’re good to go. Each time you do these, though, at least with the traditional techniques, you can only open about a third of the angle. Right? So you might be able to get a little bit more than that. But that’s about it. It can take — because you’re somewhat limited to about a third of the angle, it can take three surgeries to get the entire angle open with these traditional techniques. Let’s talk about positions of those for a second. I’m gonna switch to a new screen share. Because I love the white board. So let’s get my white board out here for a second, so I can illustrate my point here. Come on, white board. All right, here we go. All right, so I just had that little diagram there of an eye. Let’s just make this the pupil. Okay. So I said it might take three surgeries. And as I break this down, I’ve got this zone, and then more or less kind of these two zones. So we have nasal angle, inferior angle, and temporal angle. I’m gonna call this temporal out here, and nasal. This is the right eye. If I am doing a trabeculotomy, I will usually start up at the 12:00. And I will try to open — if I do a trabeculotomy right here, I can usually — a traditional one — I can usually open this angle. Or if I do a trabeculotomy here, for temporal, I can usually open this angle. But it’s tough to do a trabeculotomy nasally, over the nose. It can be done, but that’s tough territory. So usually this is my third area. If I’m starting with trabeculotomies. And I’ll do a goniotomy — which means I’ll stick my needle knife in here. And I’ll open this angle. All right? And same thing if I’m starting with goniotomy. Because the cornea is clear. I’ll start here. And it has to do with being able to turn the head and microscope sideways. So we’ll get to that. Trabeculotomy, trabeculotomy, goniotomy. That’s kind of how I break down opening this up. And we’ll touch on that a little bit more. But let’s get to some of those cool videos. Right? That’s what we want to see. Got a puppy dog coming after me here. Let’s talk about technique. Goniotomy. What is goniotomy? Goniotomy is direct incision of the abnormal trabecular meshwork that we were looking at before. Downside of goniotomy is you need a clear cornea. And even a little bit of ground glass opacity, once you get under the microscope lens, in that gonio lens, it’s really tough to see. So you need some clarity there. The advantage of it, though, is: You’re leaving the conjunctiva undisturbed, so if you need trabeculectomies or tube shunts later, you haven’t ruined the conjunctiva too much. And it’s pretty quick, and it requires basically a 25-gauge needle, and some kind of a gonio mirror or prism. So the equipment and the technique are pretty straightforward. We’re trying to incise just anterior to that iris insertion. And you’ll see the iris actually drop back, and you’ll see a little bit of white fibrotic band, as you do that incision. There are goniotomy knives that look like irrigating needles with infusion. I used to use those. Now I just use a regular 25-gauge needle, and I put it on a cannula, or I put it on a syringe of viscoelastic. And that way, if I need to inflate the eye a little bit, because of leakage, or tamponade it, because there’s bleeding, or expand the angle, I just inject a little bit of viscoelastic and I have a system that rotates the eye. So let’s look at that. Goniotomy locations, again — it’s easiest to do goniotomy from the temporal side, or from the superior 12:00 side. Just because of access to the inferior and nasal angle. You can have suture-fixated lenses. One of our videos will show you that. I like the little handheld Swan-Ganz or Swan-Jacob goniotomy lens. And I try to push the needle through the cornea without losing aqueous. But some people make an incision, and I’ll show you a demonstration of that. What are we incising? We’re incising that filmy tissue, anterior to the root, where the blood vessel loops and goes back down. You should not feel any tactile feedback as you’re sweeping that needle. If you’re feeling it gritting and sticking, you’re probably too deep and hitting the sclera. Just some gentle sweeps across there, and as you sweep it across there, you’ll see the iris fall back. Here’s a goniotomy tip. If you have a microscope that can be tilted like this one, so it is not oriented straight up and down, it is at an angle, so that the surgeon can do surgery on the nasal angle here. Another tip is: If that’s not enough, or if your scope doesn’t tilt, I simply take the patient’s head, and I turn it sideways. All right? Just make sure you don’t dislodge the airway when you do that. Tell your anesthesiologist. But you can rotate the head, and that would facilitate seeing that nasal angle, as you’re doing a temporal approach goniotomy. This advantage of tilting the scope and tilting the head is why when we do a goniotomy, usually the first place you like to start from is temporal. All right, so here’s the first goniotomy video. Let’s take a look at this. Again, this is a 25-gauge needle on viscoelastic. Another comment is you’ll see that the lid speculum is in on this case. Sometimes I will actually take the lid speculum out. And the locking forceps — you can move them back onto the inferior and superior rectus muscles. So there’s that Swan-Ganz lens, and you can see the irregular iris insertion. Just reaching across, and I’m gonna make sweeping movements like this. Sometimes you can get a nice big sweep, but look how it starts to drop back as you sever those abnormal attachments, that abnormal insertion. I just make little sweeping movements, so I can control it. And as I’m doing this, and I get towards the edge of what I can see, my assistant is rotating the eye with those forceps at the same time. And you want to practice that move before the needle is in the eye. We sit there before we start. I have them try to rotate the eye, keeping the iris plane level. And we practice that for a couple minutes, before we start the procedure. And as you get to the edges, it’s hard to see. You kind of lose visibility on that needle. And this is actually a really good view. A lot of times your view is quite hazy, due to the corneal edema. So we’ve gone one way, as far as I feel I can go, and now I’m back to straight across, and I’m sweeping the other direction. In this case, I just have saline underneath the lens, but you can also put viscoelastic underneath the lens. So I think I’m injecting a little bit of viscoelastic here. Deepening up that chamber. A little bit of leakage. And when we go back in here — you see I’m keeping the needle out in the periphery. Stay away from the pupil. I’m back in there, and we’re sweeping back to the left still. Just those little sweeping movements. Kind of going across the peripheral edges of that iris. But a little bit just in front of it, most of the time. If it doesn’t drop back, then I move a little bit more into the iris tissue. If you get too much into the iris, though, you get bleeding. A little bit of bleeding is normal. But you can get a lot of bleeding, if you’re digging into the iris, and then you’re gonna lose your view, and then you really have compromised your surgery. See how that white band to the right of the needle is opening up? That’s all angle that’s been opened with the goniotomy. So really, this is a simple thing to do. Once you get the position down, this surgery is simple and easy. It’s the visibility and the positioning, and having access to a gonio lens of some sort that’s gonna work. So one thing you’ll notice is I pulled this needle out. Again, I’m gonna keep it over the iris tissue. I’m not gonna drag this needle across the pupil. Right? That’s the one thing that you can really muck up, is if you touch the lens with this needle, this very sharp needle, you’re going to get a cataract. So you have to pay attention to that. And there’s a viscoelastic. Sometimes I’ll irrigate the viscoelastic out. Other times, I just let whatever comes out like that — and let it go. All right. So that’s one video. I think that’s a pretty good example. So here’s another example. This is the lens that I used to use. And I forget the name of it, but you suture it to the sclera like that. And it has — at the top, there’s an infusion line going to it. So it’s infusing fluid underneath the lens for your clarity of view. And then this is actually a goniotomy knife. Okay? It looks like a big metal needle. But it is an irrigating knife. And the end of it is angled up, beveled up, just a little bit. So you can help get a better approach to the angle. So it’s kind of — the end of the knife is like this, a little bit. Like a ski jump. This is reusable. And it’s hooked up to a syringe, and your assistant can — because you’re controlling the eye with the lens being sutured on there, your assistant can infuse fluid to help deepen your chamber, so you don’t use viscoelastic. Technique is the same, though. We’re out there. We’re going just anterior to this iris insertion. And we’re gonna do a little bit of sweeping across there. This is — because I’m using this equipment, I know this is pretty early in my career, so I may be a little more tentative with this. But I think this one shows a pretty good example of — there, you can see how that white band is opening up there. And that’s what you’re looking for. Seeing that iris drop back like that. So it’s a really nice example of that. And we are at an hour now. But I do have a couple more videos I want to show you. I want to show an interesting goniotomy video, I want to cover trabeculotomy, and I’ll spend the rest of the half hour taking questions. Or longer. I’ll just keep taking questions. So let me stop that, so I can keep this moving for you guys. Because I want to show you this other one. Let me pause this for a second. This is on the Orbis Flying Eye Hospital, this is Jamie Brandt, a glaucoma specialist in California. And he’s using — this is like a hybrid goniotomy/trabeculotomy. It’s a good transition to our next trabeculotomy question. He’s gonna put this needle in and it has a suture that feeds into Schlemm’s canal, and then he tears out trabecular meshwork. It’s definitely like a combined goniotomy/trabeculotomy. So let’s play that. All right. Here’s this little device. It’s like a curved needle. All right, same kind of technique. Here he’s using a 75 blade. You can see he’s making a little paracentesis. If you do this, you’re probably definitely gonna be putting viscoelastic in. So now he’s got viscoelastic. He’s filling up the eye. He’s doing a second paracentesis. And there’s the Swan-Jacob lens. And now let’s watch as he puts this little device in. Okay. So it’s hard to see the first half of insertion with the gonio prism on. You see he put the needle in, got it all the way across the iris, and there’s the point. There’s a little prolene suture coming out of the end of that needle, and he basically jammed this needle into Schlemm’s canal, and he’s extending this prolene suture out. So the suture is threading out. This suture will come out until it’s about 180 degrees around internally. And then he’s basically just gonna pull that needle back, and it’s gonna tear out Schlemm’s canal like a trabeculotomy, but from the inside. All right. So it’s like a trabeculotomy ab interno instead of what we would normally do external. All right. I’m gonna stop it there, but basically what he does, then, is he goes back in, retracts that prolene, goes back in, and does it the other direction. He’s opened 180 degrees to the left and another 180 degrees to the right. So basically a 360-degree goniotomy/trabeculotomy. Which is great. I’ve not used that device. I don’t know how much they cost. I’d love to get my hands on one and try it, though. It seems pretty cool. But again, disadvantage — spoiler alert — disadvantage here is you have to have a clear cornea. So many of the patients you and I see get referred late and the corneas are cloudy. That’s why I’m telling you if you’re gonna learn one technique that you can do on everybody, it’s this next topic, trabeculotomy, because it does not require a clear cornea. So disadvantage: Schlemm’s canal might be absent or difficult to find. You know, usually in congenital glaucoma, Schlemm’s canal is still okay. But not always. And you still — if you do this traditional technique with these trabeculotomes, you’re only opening up a third of the angle. There are 360 trabeculotomies, which is cool. In this clip, this is insertion of the trabeculotome, and then the anterior chamber — see the arm. We’ve got aqueous coming out. So why are there two arms on the Harms trabeculotome that you can see here? The bottom one, at the top of the screen here, is the one that does the work. The one on top that you see over the cornea — it’s just there to tell you where the bottom one is. You could have a one-arm trabeculotome, and that would be fine. The second arm is just so you have a reference as to where you are with the first one. Okay? That’s the reason for that. That’s the real deal. Now, we didn’t cover creating the wound. This is a little bit of a step by step series of photographs. Let’s talk through them. You can use any kind of blade. Trying to get a half thickness or so dissection down. And up into clear cornea. See, we want to see that blue cornea there, right? Now, once you get up into blue clear cornea, what are we looking for here? Let me go back here. So here, if I’m looking for Schlemm’s canal, the structure to identify is this blue-white transition. Right there. The blue-white transition. And then I’m gonna make a radial cut, about 2 millimeters long, that straddles that blue-white transition. You can sometimes find things, like leaking aqueous veins or bloody aqueous veins. I think that’s one right there. Maybe we’ll see some more later. Schlemm’s canal is usually just in front of those. Those are the landmarks to help you. A couple millimeter, two or three millimeter radial incision. You see this dark area. That’s where I’m gonna think Schlemm’s canal is. It doesn’t really look like a blood vessel cut in half. It’s not quite that distinct. But you’re looking for that dark wet deeper coloration there. And that’s what I’m gonna try to cannulate. So blue-white transition, radial incision across that. I like to precannulate with prolene suture. Helps me — if that suture goes in easy, and does not appear in the anterior chamber, that tells me I’m in the right spot. If I get resistance with that suture or it appears in the anterior chamber, I’m in the wrong spot. I put it in both ways, because usually once you tear your trabeculotome one way, a lot of this times you’ll lose your anterior chamber. It’s hard to find the second side. So I kind of use it as a marker, before I lose any chamber. Now I’ve got my Harms trabeculotome, go in on one side, take the suture out, try to advance this to its full extent, but usually you have to back off just a little bit. If you’re feeling resistance, you’re probably in the cornea. If you’re seeing the iris move or you’re behind the iris, you’re too deep. So you have to adjust your position just a little bit. So you notice in that last video we had a lot of aqueous loss. I try to rotate not past this point, until I’ve done the second side, because if you rotate up to 90 degrees, you’ll all of a sudden get a lot of leakage out of here. So I’m just tearing open the meshwork and I’m gonna go back out, go the other way, and then I’ll do it all the way across. Just a little trick to help preserve your chamber and hopefully not have to put viscoelastic in. If you do have to put viscoelastic in, it’s fine. I do it all the time. A little bit of blood reflux again, with goniotomy and trabeculotomy — that is normal. Does not bother me. I expect to see that. If you don’t see that, I’m actually probably more bothered by that. So second side, advancing the trabeculotome. And you see the chamber looks like it’s getting a little shallow to me. That iris looks like it’s bowing forward. There’s our trabeculotome coming out. And then rotating. And then that radial incision — I usually don’t close that. I usually just tap down the flap and pull the conjunctiva back forward. I think in this case, I am closing it. But I usually would just tack down that flap. I’m gonna show you one more video, and then we’re gonna go to the questions. Let me just forewarn you. We have 141 questions in the queue. We have 772 participants with us right now. I will keep going through these questions after I show you this next video, and that will be the rest of what we talk about. And we’ll do the rest of this lecture maybe some other time, because this is good stuff, folks. All right. Let’s just talk about 360-degree trabeculotomy. This has been described 20, 30 years ago, using that same prolene suture. You just feed it in, and it goes all the way around. And I did that for a while, and it worked. Sometimes the suture would get hung up. And I did it, until I had this problem. I had a suture which left Schlemm’s canal. And this was a preoperative photo of the patient’s posterior pole. This was a postoperative photo of the patient’s posterior pole, taken a few months later. And that prolene suture hit an obstruction, or just left Schlemm’s canal, and it tracked right back through the subretinal space, in the choroid. It was in the choroid. It comes right back through, it’s scraping the retinal pigment epithelium off. That is almost like a dead-on hit on the fovea. Now, it did not affect the patient’s vision, fortunately, but it left this mark, and the problem is: The distance from Schlemm’s canal to the fovea is shorter than the circumference of feeding that thing around. So unless you can monitor it with a gonio lens, it can get to the fovea before you know — before you’re expecting it to exit again. So I stopped doing it until they come out with this microcatheter system. Now, these were developed for putting tension sutures inside Schlemm’s canal. But it’s a perfect way to do 360 goniotomy, because there’s a canal, a lumen, that you can inject viscoelastic through, and then there’s this fiber-optic light. The fiber-optic light is what I’m really interested in. Same kind of thing. Here’s — we’ve done our dissection. We’ve got our blue-white transition right here. Here’s one of these veins I was talking about. I’m looking for these little bloody aqueous veins. They’re usually right behind, right posterior, or right over Schlemm’s canal. A little radial incision. Until we start to see that blue shiny wet canal. It looks like starting opening up there in the middle, that’s what we kind of like to see. Now, here’s that prolene. And you can see — that’s a 6-0 prolene. And you can see the cannula next to it. It’s bigger than the 6-0 prolene. Might be twice the diameter. But it still should go into Schlemm’s canal without resistance. This light — you can set that light to be blinking, or on continuous. But now, as you feed this around, you see exactly where it is. And I’ll turn the microscope lights down so you can see it better. If all of a sudden, you see it out in the conjunctiva or sclera, then you know it’s left Schlemm’s canal and you stop. And what I’ll usually do is I’ll attempt these as my primary procedure. If it doesn’t go all the way around, I usually just pull it out and do a traditional trabeculotome. If it does go all the way around, then you have the ability to open Schlemm’s canal 360 degrees, just like that little needle device that Dr. Brandt was using internally. But you have the benefit of — you can do this through a cloudy cornea. You can see this cornea is pretty hazy. I don’t think you could do a goniotomy procedure through this. You just wouldn’t be able to see very well at all. So you can, if you get stuck — let’s say you get stuck there. You can do a cut-down and just take what you can get there. That sounds easy. I will tell you in practice, finding it on a cut down can be difficult. But when it comes, this is a beautiful thing. And here the light’s back around to our exit. And what I found best for retrieving this out of the cut — I think at this point, I’m using forceps, but since I’ve found that a little Sinskey hook — you can just sweep this out of there with a Sinskey hook, and then grab it with the forceps. All right. So once we’re back around, here’s the forceps technique. I think it’s cumbersome, and I don’t like it, because you’re grabbing a lot of stuff down there, but this one worked out okay. Now we’re gonna grab the two ends of this, and basically it’s going to just pull all the way across the anterior chamber, and open that angle 360 degrees. I think I can see it coming through already. We’re gonna watch this area up here. I think it’s right here on the iris. Some of this is reflection from the speculum. Coming. Should see it here in a second. Yeah, okay. So now we’re starting to see it come across. I just pointed it out in the video. And here it is. You can see the iris is sweeping here. There it goes, across the pupil. You’ve just got to watch this here, so you don’t pull the iris out and get it incarcerated. Sometimes I’ll pull that end and let it loop back out. Otherwise you pull the iris sector there. So now it’s out. Stop, stop, stop. Yeah. Let me go back. All right. There’s a view on another patient with blue eyes. You can see that thing coming across. Basically that’s what happens. All right. Enough about that. Let’s get to some questions, and we’ll do these, as much as we can. Hey, Lawrence, will you do me a favor? Will you message Hunter and let him know I’m gonna be late? I’m gonna work through these questions. >> No problem. DR NEELY: Okay, thanks. Let me stop the share. Let’s go to some questions. We have so many great questions here. All right. So here’s a patient. My patient is a 12-year-old boy with glaucoma. Both eyes. And has had a trab and a PI in both eyes but has 0.95 cupping. What can I do for further management? You say they have a trab and a PI? I’m assuming you mean a trabeculectomy. I think it depends to some degree on availability of resources and what you can do. If this is a congenital glaucoma patient or an inflammatory glaucoma, where we think the angle is abnormal, I do think that goniotomy or trabeculotomy in another area are good options. Frequently what I find in this age group is that I’ve gone through everything else, and what I’m going on to do is tube shunts. And I’ll just mention that my preferred tube shunt is an Ahmed valve. I like the valve in terms of short-term pressure control of hypotony. I think it’s also known, however, that the larger valves, like the Baerveldts, maybe give better long-term control. So they’re both — all the valves are quite useful. They will get the pressure down all the time, but they just have high rates of complications. Probably 25% of my patients with tube shunts have some kind of mild or moderate complication that we have to deal with. Here’s a question about the prospectives of MIGS in pediatric glaucoma. There’s a lot of interest in this, and I don’t have a lot of direct personal experience with MIGS so far. I think the question really here is: Whether one is enough, or if you need multiples. Again, we have abnormal angles. So I suspect that as a primary procedure for congenital glaucoma — it’s probably not going to be the answer. But as a secondary procedure, or in congenital glaucoma, after the angle has been worked on, or as a procedure in a secondary glaucoma, that it probably has potential for those. Tips to identify Schlemm’s canal during pediatric glaucoma trabeculotomy surgery? It was just in those videos. Let’s reiterate. Dissect your flap into clear cornea. One of my partners doesn’t even make a flap. He just starts cutting down. The reason I do a flap is it makes it easier to identify that blue-white transition, because that’s my landmark right there. I need that blue-white transition, and then I’m doing my radial incision across that blue-white transition, and I just stay in that same plane, until I start to see some fluid, and then that’s usually Schlemm’s canal. Occasionally you don’t find it. It can be a frustrating procedure. Or it can be abnormal. You know? Or if you have a really buphthalmic eye, it can be displaced posteriorly. If you have a cornea that’s 14, 15 millimeters, you may have a hard time finding Schlemm’s canal, just because it’s so displaced. Question about management of glaucoma associated with cataract surgery in children. Please discuss. So this is a big part of the second half of this lecture. When I’m treating glaucoma in children with cataracts, I’m usually not doing the angle surgeries that we’ve discussed. I’m usually doing either tube shunts, because trabeculectomies tend to not do well in aphakic/pseudophakic patients, so either I usually do a tube shunt, or a thing that we really like is mild forms of cyclodestruction. Endolaser of the ciliary processes, you can do external G-probe laser, recently we’ve switched to the micropulse laser, which fragments — so it’s not just one big blast of laser. You’re sweeping around the limbus, and it’s giving fractions of laser to the ciliary body. Those are probably our more likely options in that category. This was a question about the medications. Covered that. First drug choice. Covered that. Recommendations for anesthesia. We covered that. Here’s a new one. I have a patient, 18 years old, with mucopolysaccharidosis. His pressure is about 23. With a pachymetry of 540 microns. What treatment would be the most efficient? Well, I don’t know. I think someone like that — a lot of this can also depend on what does the optic nerve look like. Just because the pressure is 23 doesn’t mean that I have to do treatment. Right? But I think just like a topical drop would be my go-to, unless you’re seeing changes in the optic nerve, despite maximum medical therapy. And of course, you have a relatively thin cornea. It’s not one of these 1,000 micron corneas, like we see in some of the congenital kids. Okay. We talked about repeated anesthetics. We talked about OCT. How frequently do you get nerve fiber layer defects? Well, I think our history of OCT and following kids over time is limited enough that I don’t know how many of them have nerve fiber layer defects. The really young kids can’t do OCT, of course. So I don’t have a good feel for this so far. It’s a good question, though. We talked about operating on congenital glaucoma, as soon as it’s safe. Depending on your anesthesia abilities. Would you do surgery on eyes with a pressure of 10 if there is cupping and buphthalmos? Well, it depends on if we’re talking about — have they had any surgery before? If this is someone who’s not had any surgery before, then yeah. I suppose you would. If there’s progressive cupping and buphthalmos, then something is not right. However, if you have an eye with cupping and buphthalmos, and they’ve had surgery already and the pressure is 10, no. I would not operate. I would watch that. All right? Commonly after surgery the pressure is asymmetric in two eyes, but below 20. Does this mean the higher pressure needs more treatment? Okay. So both eyes, the pressure is now below 20, but it’s not the same in both eyes. Does this mean you have to make them equal? No. I don’t think it means you have to make them equal. But you are going to pay attention to the other parameters here. What’s the optic nerve doing? What’s the axial length? Those are gonna be the things that make your decision. Not the pressure being asymmetric. Especially postoperatively. Right? If the patient has a normal cup to disc ratio, but a high intraocular pressure, over 30, and large cornea, what would be the treatment? Well, any time I see a normal cup to disc ratio, I go a little more conservative with things. Now, a pressure over 30 is pretty high, though, and a large cornea is also concerning. So I suspect I would intervene in this case. If we had a pressure that was mid-20s, in a large cornea, but a normal nerve, I might ride that. But this sounds like someone who needs surgical intervention. Does OCT have normative data for the pediatric population? Some. It’s still limited. But there is normative data in the literature. But just like with lens calculations and results, the information that we have in the pediatric population is limited, compared to the adult population. And we always have to take these things into consideration. You can’t just apply adult data to children. This question. Without examination under anesthesia, how far can we diagnose glaucoma in babies? Oh, I think you know it when you see it. In a baby that has a large cornea, or you can’t refract after you dilate them, because the cornea has enough ground glass haze, you can be pretty certain that that child’s probably got glaucoma. One way to try and measure the pressure in the office is to let the baby feed, either on a bottle or on the breast, and a lot of times we can get pressures in infants in the office that way. But yeah, clarity of your red reflex, estimation of your corneal diameter. Look at the refraction. See if they’re myopic. All these things can be done in the office. When we do an EUA, most of the time, we’re just confirming what we already know from the clinic. And then we’re doing the surgery. The EUA is just what we do before we do the surgery, most of the time. Right? We usually have a pretty good idea, I think. Question about what age in children is OCT and PFV a reliable tool. It just depends how much they can cooperate. Just like lens implant calculations. I can get IOL calculations on some 5-year-olds in the office and not others. And if I can’t do it in the office, I do it under anesthesia. There’s just a lot of variability there. I don’t think there’s an absolute answer. Like so much of pediatric ophthalmology, the kids are just different, and there’s no age that you can define. Another question about clinical diagnosis: How difficult is it to diagnose pediatric glaucoma clinically? And is it really theoretical sign present as they are? As I mentioned, I think it’s quite easy to tell this in the office, and usually the EUA is confirming what we already know. Now, if someone had totally clear corneas, and a normal refractive error, but the corneas were large, or say they had big corneas and high myopia and a clear red reflex, but you couldn’t get a pressure, that’s someone you might need to do an EUA to document a pressure, but usually these aren’t subtle. And if you have to follow someone, you just follow them closely, and see if anything changes. Do you see spontaneously arrested congenital glaucoma? Yeah, I think I have seen this a few times, where someone comes in, and they’ve got changes to the structure of the eye, but now the pressure is normal. I do think I’ve seen that. Is it common? No. It’s not common. But I know I’ve seen this a handful of times. Can you talk about glaucoma in children with corticosteroids for asthma. Inhalable and systemic. What’s the frequency of ophthalmic follow-up? I don’t think that I’ve ever seen it from inhaled steroids. I do think that we see it from topical steroids, of course, and in a lot of countries, people can buy topical steroids over the counter, and they use them for conjunctivitis and allergies without any supervision at all. With oral steroids, yes, we see that too. If someone is taking chronic steroids, and by that I mean — say more than a month or two months. If they’re taking chronic steroids orally, or otherwise systemic, I would probably follow them every three months at first, and make sure that they’re not a steroid responder. But inhaled steroids — I don’t think I’ve ever seen glaucoma secondary to inhaled steroids. Do you make an IOP correction with pachymetry? We touched on that just a little bit. A little bit. I don’t put a big amount of correction in with that. But clearly, if I measure someone with a 1,000 micron cornea, and their pressure is 25, I’m probably okay with that. That’s a pretty thick cornea. But I think the days of having scales and adjusting so many points based on corneal thickness — I think that’s largely been disproven in the adult population. So we measure it. We record it. I don’t make huge corrections for it. What is your next surgery if a patient fails with the first angle surgery? Well, the next surgery for me kind of depends on — if they fail one angle surgery — hello, cat — and I only opened a third of the angle, then I go on to another quadrant. So if I did a superior trabeculotomy the first time, I’ll do a temporal trabeculotomy the second time. And I just work around the angle, until the entire angle is open from either goniotomy or trabeculotomy. So that’s up to three times. Once I’ve done all three quadrants, three sectors of the angle, then I move on to other things. And that other thing is usually a tube shunt, at that point. And we’re doing pretty good on questions. We’ve now answered 48. We still have 134 questions, and we still have 602 participants, so I will keep going. In eyes with congenital hereditary endothelial dystrophy or Peters, or any other scarred cornea, which tonometer would you rely on? If you have a scarred cornea, I still like to use the Tono-Pen, but I take the measurement in a clear area of cornea. Okay? If you find that you can’t get to a clear area of cornea, my next choice would probably be applanation of a larger area, say, with a Goldmann or Perkins. I think the best device for a scarred cornea is also the one that’s hardest to find, and that’s a pneumotonometer. We used to have one. I don’t anymore. But I think that has been shown to be perhaps the most accurate in scarred corneas. So just try to get over a clear area, is the easy answer. Even if that means you’re not in the central cornea. Question is: Whether there will be any depression of the eyes into the socket. And how we can identify the laziness of eyes in such cases. I don’t think you see any retrodisplacement of eyes in the socket. Certainly the eyes can become buphthalmic and protrude out of it, but if you control pressure, I don’t see that the eye regresses into the socket or shrinks. What is the most common cause for childhood glaucoma? If you have to look at what we see most in the clinic, it’s probably aphakia/pseudophakia. So 25% of all childhood glaucoma is congenital or primary. Probably the next most common group is aphakia and pseudophakia. And then we see probably the post-uveitic glaucomas or traumatic glaucomas. And then we start to get into aniridia and Sturge-Weber. Probably the top six list there. Sometimes neurofibromatosis. Another question about corneal thickness and pachymetry. We’ve covered that. Please suggest the best book on perimetry. As residents. A little off-topic, sorry. Gosh, that’s a good question. I’m not sure I have in mind offhand a great book on perimetry. I’ll keep that one in mind, and see if I can find an answer for you. If anyone has a suggestion for a perimetry book for teaching, throw it in the chat and I’ll read it out here. Can you do visual field testing for a child? Again, very age-dependent. We use an octopus or Humphrey field analyzer, and some kids can do it, some kids can’t, and we keep trying until they do it. Usually the first time they do it, it’s terrible, but we get a baseline, and if it looks bad on the first one, I just have them do it again six months later. We do have a Goldmann bull perimeter. I find some kids can do that easier, but it’s hard to find someone who can administer that test. Again, it’s just the variability we have in the patient population. Some can, some can’t. You keep trying. Do you use axial length curve to monitor glaucoma control in these children? Yes, in the young ones. Now, after age 4 or 5, they’re no longer going to have progressive buphthalmia, so they won’t have axial length changes related to the pressure. They may have axial length changes related to the growth, but I can’t attribute this to the pressure. I’ll follow it in younger kids, up to 5 years old, and I do use that as a measure of control, especially comparing one eye to the other. If one axial length is changing faster than the other, something is wrong. If you’re gonna see axial length changes, they should be symmetric in both eyes over time so that’s a good tool. All right. Next question. How can I follow a child with congenital glaucoma? Operated at 3 months with nystagmus. He cannot do perimetry or OCT. Those are great tools, and we use them in adults. Young kids, I don’t use them at all. You can’t do it. This is pediatric ophthalmology. We can’t do the same things that you can in adults. So we do other things. We monitor the refraction. In a young child, if they’re getting progressive myopia, especially if it’s asymmetric, the pressure is not controlled. If you need to do periodic EUAs in this case, a three-month-old with nystagmus, you do that. Maybe you do an EUA every six months until you can get that stuff in the office. Measure axial length under anesthesia. Take pictures of the optic nerves, if you can, or just do drawings of the optic nerve at the EUA. So you can’t do perimetry or OCT in a 3-month-old, but we’re collecting data from about six different things that are other tests, that are probably as useful or more useful in this age group, let’s say. A question about Haab’s striae, and why they tend to be horizontal, but Vogt’s striae are vertical. The direction of those — let’s see if I know the answer to that. I don’t know if I know the answer. We talk about it being characteristically circumferential with pressure, and maybe that’s just because the cornea is expanding equally in all directions. And so you get this circumferential break. Which we see. And then we talk about the horizontal ones. Now, why would it be horizontal and not vertical? That doesn’t necessarily make sense to me. I don’t know the answer to that. And we talk about forceps trauma being oblique. But why it’s a specific direction is not intuitive to me either. Okay. How often do you follow pediatric glaucoma after angle surgery? That’s a good question. So I just recently had a new kid, infant, that I did goniotomies on. And he’ll go back to the operating room about a month after the surgery. And I’ll recheck his pressures, and his parameters, then. And if he needs more surgery, I’ll do it then. So I don’t do it right away. Once I’ve operated on one or both eyes, depending on if it’s unilateral, bilateral, I’ll usually wait about a month to six weeks, and then go back to the operating room and decide if that worked. I don’t think there’s any sense in going earlier than that. After you feel like the pressure is controlled, I might do the next EUA in six months. And if they seem to be doing well after that, it’s kind of variable. I may never do another EUA again, if things look okay. Someone is saying I haven’t used iCare. How do you use it? It’s pretty similar. It’s got a little forehead rest, and iCare, instead of having an applanation like a Goldmann — so Tono-Pen has a little plunger, which gets depressed by the cornea. iCare fires a little — I don’t want to call it a dart, but it looks like a little dart, and then it measures the rebound speed of that little tiny dart off the cornea. And that’s how it estimates the pressures, the rebound speed of that. It’s a nice tool. And again, doesn’t have to require anesthesia. A lot of kids tolerate it better than Tono-Pen. Will you be using finger pressure when you don’t have any equipment to test for elevated intraocular pressure? I do. We do it in the clinic all the time. I almost feel like it’s more for show than for accuracy. If an eye feels high on palpation, there are probably other signs that you’re gonna see, that confirm that that pressure is high. I don’t think it’s ideal. If that’s all you have, that’s all you have. And if you are in a situation where you have to do glaucoma measurements by palpation, then what I suggest you do is that you do it on all the kids, all the time, so that you know what a normal one feels like. That way, when you have one that’s 30, you can tell. You’ve had that experience. This is analogous to doing traction testing for superior oblique palsy. If the first time you’re trying to pick up a lax tendon is when you’re operating on a superior oblique palsy, how do you know it was lax if you never did it on a normal one? You have to do it on the normal ones to know what abnormal feels like. So that’s what you have, that’s what you have. And that’s what you do. How can we differentiate congenital/hereditary endothelial dystrophy from primary congenital glaucoma? They both can have cloudy corneas, but other than that, that should be your only overlap. Pressure should not be elevated. Corneal diameter should not be increased. Refraction should not be myopic. Optic nerve should not be cupped out. Axial length should not be increased. So again, it’s all these other parameters which are important. But yeah. You have someone with congenital hereditary endothelial dystrophy, and you’re not certain, do an EUA. What shows that the eye does not tolerate the pressure? If structural changes are happening to the eye, it is not tolerating the pressure. Again, corneal diameter enlargement. Axial length changes, showing up on biometry or refraction. Optic nerve changes happening over time. If there are physical changes happening to the eye, it is not tolerating the pressure. Why is it so difficult to manage Sturge-Weber and aniridia? The scientific answer to that is because they suck. They really do. Sturge-Weber and aniridia — you know, I think it’s the mechanisms here, to some degree. Sturge-Weber, we have an outflow problem. And maybe we have an increased inflow problem. So they’ve got all this extra blood flow, which increases episcleral venous pressure. The outflow is really limited, and maybe all that extra blood is causing increased aqueous production, because the ciliary body is hyperperfused. I think with Sturge-Weber, that’s the answer. It’s this outflow issue. I usually find I have to do tube shunts on those patients. Word of caution: That is also the one pediatric group where I see postoperative hypotony being a factor. If you are doing tube shunts in the Sturge-Weber group, leave the tube tied off. Use a tube with a valve. Leave viscoelastic in the eye. Because I’ve had several cases of kissing choroidals, especially in these teenagers with Sturge-Weber. That’s a tough group to deal with. Aniridia? Why are they so bad? I don’t know. Of course, they have some angle abnormalities with the iris being absent. You can assume that the trabecular meshwork is also absent. Not absent, but affected. Maybe their Schlemm’s canal is actually maldeveloped. I don’t know that I’ve seen any studies on that. But it would make sense to think that maybe with aniridia, Schlemm’s canal could also be affected, and that’s why they’re so tough. They’re also tough because their corneas are compromised, with the stem cell issue, and so they tend to get cloudy corneas, scarred corneas, that opacify. That makes them a tough act too. The other thing with the aniridia that’s tough is: You can do angle surgery on some of them, but if you have to put a tube shunt in, you have no iris to protect the lens of the eye from the tube tip. So now you’ve got someone who is likely to get corneal failure from aniridia and tube tip contact, or they’re gonna get cataract, because there’s no cushion between the tube tip and the lens. So that’s why I really don’t like those two kinds of glaucoma. Will you tell me your first choice of eye drops, and if you combine, which is your second choice of hypotensive? We mentioned this, but I’ll touch on it again. Beta blocker would probably still be my first choice in young kids. And the second one I add is usually aqueous suppressant. Like carbonic anhydrase inhibitor. Beta blocker and dorzolamide or one of the other — especially in combination. So Cosopt, dorzolamide, and beta blocker, that’s usually one of my first off the shelf choices. If I need a third one, I usually add a prostaglandin agent, or try brimonidine, if it’s an older kid. And everyone’s gonna have personal preferences on this. I don’t know that we know the answer. I just know that the prostaglandin agents with me haven’t been super effective. Now, if I had a kid, not congenital glaucoma, not an infant, if I had a kid with juvenile glaucoma, I probably would try a prostaglandin agent. I like the fact that they’re once a day dosing. So just not super impressed with the efficacy. Is there any standard to perform intraocular pressure measurement? EUA in all initial cases, or according to the child’s cooperation. According to your experience, how many millimeters is the difference between IOP measurement under anesthesia, asleep and awake? I touched on that, the difference between awake and asleep. The difference between awake measurement and asleep measurement after intubation, and after they’ve been under gases for a while, is probably in the ballpark of 5, 6 millimeters. I think that’s pretty standard. Do I do an EUA in all initial cases, or according to the child’s cooperation? That. According to their cooperation. If I can get the data that I need in the office, I will always go that route. But if the child is uncooperative and I have a strong suspicion or concern of glaucoma, then we do an EUA. And EUA can either be just a quick mask down and measure the pressure, or EUA can be intubated and a whole series of tests and recordings being done. There are whole different levels of EUA. We don’t do it in my hospital, but some people might do conscious sedation for EUAs. So if your hospital is equipped to do that, propofol or whatever, you can do that. No right or wrong way. Our hospital is not a big fan of us doing conscious sedation, and we’re not really equipped to do it, so we usually are doing it in the operating room with an anesthesiologist. Do you ever use ketamine for EUA? I was thinking about that too during the last question. The answer is no, I don’t. You can. However, what’s the disadvantage of ketamine? The disadvantage of ketamine is the rapid eye movements that they get. I’ve done surgery under ketamine. And it’s a bit of a challenge. Because you do get eye movements. Because you get eye movements, you probably are getting some increased pressure. Because the eye muscles are contracting. So it can be done, but if I was using ketamine for an EUA, I would factor that into my opinion of the intraocular pressure. And I would probably be collecting data other than the pressure to support the diagnosis. So it can be done. At which age is ready for visual field test? Yeah. We talked about that a little bit. Again, it’s just variable. When do I first try it? School-aged kids. Never under that. I don’t think any kid under school age can do an automated visual field. Most of these kids — even these teenagers, a lot of teenagers can’t do visual fields. There’s definitely a lot of variability there. You try it. If it doesn’t work out, you try it again next year. That’s kind of my technique with it. Starting at school age, and then keep trying to see when they can do it. In cases with corneal opacities, Peters anomaly, is intraocular pressure measurement on corneal scars not reliable? It is not. If you do an intraocular pressure measurement on a scar, the cornea is thick, the cornea is stiff, and therefore there’s more resistance, and the pressure reads artificially high. You need to get onto the clear cornea to measure the pressure. Does LMA help? I assume you mean laryngeal mask anesthesia. Does that help over endotracheal tube? No. I think kind of the same deal there. We use both. My only comment about LMA versus ET tube is that the LMAs tend to stick up more. If you’re doing something under the microscope, there’s a little less room for passing instruments back and forth, because the LMA tends to come forward. There are ways to redirect it, but that’s about it. Okay. You guys are amazing. We still have 500 people on. We still have over 100 questions in the queue. And we’ve answered 68 so far. We have 133 open questions. I will keep going, as long as you guys want to sit there. You’ve got it. Someone bring me lunch. All right. At what time do we start giving a child neuroprotection, when we still are in the suspect condition? I don’t think I ever use neuroprotective agents, necessarily, in kids. I think even in adults that data is soft. I don’t think there’s a big role for that at this point. If someone else has had a different experience, I would love to know. But I don’t think you’ve seen any controlled clinical trials on neuroprotective agents in children. Any data that’s there is anecdotal, and I think that question is unanswered. Does the corneal edema resolve after correcting the intraocular pressure? If not, what should you think of if corneal haze persists? It does not always resolve. Here’s the deal. It seems to depend on two factors. If it’s there when they’re born, it is less likely to clear up. If a child is born with corneal edema, corneal scarring, it usually stays there. Even when you get the pressure normalized. So don’t always expect it to happen. If they have more of those kind of just hazy ground glass corneas, those usually will clear all the way, once you get the pressure under control. If someone’s pressure — even if they’re not born with cloudy corneas, if they have high pressure for a long time, enough that they get some actual corneal scarring, it may fade, but it may not go all the way away. So pay attention to it. But it doesn’t necessarily tell you anything specific about whether they’re controlled now. Because it really depends on: When did it start? Were they born with it? And how bad is it? Is it just fluid, or is it actual corneal scarring haze? How do you do gonioscopy during an exam under anesthesia? The pupil is meant to be dilated, so how does it work? Right? That’s actually a good question. Because when we do a glaucoma EUA, we do not have the patient dilated. You’re gonna say: Well, you can’t see the optic nerve, then. Right? Maybe not. But what we want — when we go to an EUA, what I want is to measure the pressure, see what it is, and I want to look at the angle. And if I need to do an angle surgery, I want that pupil undilated. So I do not dilate them. If I do an EUA and I decide I’m not going to do surgery, then I will dilate them and we will wait. I try to avoid that, but sometimes that’s what we do. I wait until the pupil dilates until I can see the optic nerve and take a picture of the optic nerve, and while I’m waiting, maybe I’ll measure axial length, maybe I’ll refract, maybe I’ll sit there and tell jokes. Who knows. But yeah. We specifically tell our residents: Do not dilate the glaucoma EUAs. We do not want them dilated. Now, you can reverse the pupil with Miochol, Miostat, those kinds of things, if you need to, but it’s not ideal. So do not dilate them, unless you do not plan to do a surgery. Why does enlarged optic nerve regress? Again, I think it’s because that scleral ring regresses. Pressure comes down. Pressure on the scleral ring in the sclera goes down. The scleral ring was stretched out, scleral ring comes down around the optic nerve. So that nerve tissue — it’s the same. It’s like having clay or play dough. You can smush it out, and then the pressure comes down, and it comes back in. So I think it’s just that scleral ring contracting back down to a normal size. Eventually sclera doesn’t change shape anymore. You don’t see any regression. And that’s around age 4 or 5 again. Something like that. Would micropulse laser, TLT, or transscleral cyclophotocoagulation is better? We’ve done both. I’ve done a lot of transscleral. I’ve done a lot of endolaser, and more recently, we purchased the micropulse laser and we’ve done that. I think micropulse laser, in my opinion, is the least effective so far. It has some advantages. In that it is maybe less likely to have complications. It’s easy to do. It’s non-invasive. But I’m not super convinced. I would love to go back and review those results, and give you a real good answer. Transscleral laser versus endolaser. Results in the literature show roughly equal efficacy. My preference is: If someone is aphakic/pseudophakic, I’m pretty quick to do endolaser, because the lens is out of the way. I can put that laser right on the ciliary processes and see what’s been treated and what’s not been treated. You don’t always — when you do external laser, especially if you have a buphthalmic eye, transscleral, maybe that ciliary process isn’t under a normal position. So you can try transillumination. I find it very difficult to do, so my preference is actually endolaser. But if I have someone that I’m afraid to operate on, or don’t want to do something inside the eye, or they’re phakic, I would probably go micropulse laser. The jury is still out on that for me. When you have to start choosing between tube shunts and cyclodestruction, those can be tough choices sometimes. Please explain again why the cup to disc ratio reverses after surgery. All right. This comes up a lot. Let’s go to the white board for a second, and see if I can clarify this a little better. Here it comes. So two patients. Let’s say the pressure is 40, then they have surgery, and now the pressure is 15. All right. The optic nerve, when the pressure was high, the nerve looks like this. Okay? This is our pink. And that’s our cup. Keep talking about the scleral ring. Scleral ring — there’s the sclera. That nerve comes through the canal. And that’s the scleral ring. When the pressure goes down, the eye shrinks a little bit. Okay? You see a little bit of regression of the axial length. You see a little bit of regression maybe of the corneal diameter. You see a little bit of regression of the refractive error. Less myopic. And you also see a little bit of regression of that scleral ring. Let’s say the scleral ring is this size now. Because the pressure has come down. All right. So you have this same mass of nerve tissue. Now in a smaller circle. So if you take the same mass of nerve tissue, and you put it into a smaller circle, that makes the cup smaller. Okay? So the red — the nerve tissue — is equal in both these examples. But it’s in a smaller package on the right side. That’s why the cup seems smaller. The whole nerve is smaller. The nerve tissue is in a smaller package now. All right. Let’s go back to the questions. All right. So we covered that. Cup to disc ratio regression. What is the normal corneal diameter in infants? Important to know. Newborn is probably 9.5 to 10.5 millimeters. If you have an infant with a 12 or 12.5 corneal diameter, you need to look real carefully to see if they have glaucoma. Yeah. So a newborn infant, an infant under six months, should be in the ballpark of 9.5 to 10.5. Maybe 11. In that ballpark. Okay? And then symmetry between the two sides, of course. All right. Is it possible to have a low intraocular pressure in pediatric glaucoma? Low as in normal, or low as in too low? So it depends on how low we’re talking. You can have an infant with congenital glaucoma, and actively see changes in that eye. That it’s getting worse, and the pressure is less than 20. I have operated on eyes like that before. Would I expect to see a pressure of 10 and needing something done? No, that would be very unlikely. Okay? But it’s this kind of borderline area, where if we’re talking low is 20 or 22, yeah, you can definitely have that still needing to be treated. I don’t think I see normal tension glaucoma in the pediatric population. If I do, I’m missing it. I can’t say that’s not there, but I don’t seem to really feel that that’s an issue. And it’s probably because younger people in general don’t have vasculopathic risk factors. They don’t have hypertension. They don’t have diabetes that’s been there for a long time. They don’t have high cholesterol. So their vascular system and sensitivity to microvascular disease and normal tension damage to optic nerves is probably pretty low. Kids are pretty resilient. Right? Now, can you have the pressure go too low from surgery? Yes. And you can get hypotony. Especially if you overdo cyclodestruction or tube shunts. Can you see pressure too low from doing angle surgery alone? Like goniotomy/trabeculotomy? No. I’ve never seen that happen. It’s only after been those other two procedures. Do intranasal steroids make the ocular tension levels go up? I don’t think I’ve ever seen intranasal steroids cause secondary steroid response glaucoma. At least, I’ve never identified that. So inhaled or nasal — I don’t think the dose is high enough. I think you only see it with topical on the eye. And oral. Or otherwise systemic. Now, is it possible that — there are some case reports of nasal or inhaled steroids — yeah. But I don’t think it’s real common. Is there a way to know for sure that a young patient with glaucoma has glaucoma without using anesthesia? No one thing is diagnostic. Right? So you talk about all the things we’re measuring. You have to look at the constellation of things. We’re gonna beat this to death. You’ve got to look at the corneal diameter, see if it’s symmetric or increasing, the axial length, the refractive error, if they’re showing increasing myopia, especially if it’s asymmetric, suspicious. If you see changes in the optic nerve. You know, all these things. OCT. Visual fields. About 10 things we’re talking about here. You look at that constellation of things. Whatever you can record and identify, and you make your decision based on that. But there is not one thing. And the pressure is not one thing either. If someone has a pressure of 30, that does not mean they have glaucoma. You do not have glaucoma until you have damage to the eye. Right? You have ocular hypertension. You have to look for the damage. That’s when you have glaucoma. Something has to be changing. Do you perform trabeculotomy with trabeculectomy? Yeah. So I have. I don’t do it commonly. What happens — so doing trabeculotomy and doing a trabeculectomy at the same time. A few of us in my practice do that on occasion. When do we do that? It’s usually when we think the trabeculotomy wasn’t very good. You’re doing your trabeculotomy. And Schlemm’s canal is hard to find. Maybe you don’t find it. Maybe you get it on one side, but not the other. And you’re like — eh, that was pretty crummy surgery. And then instead of just closing things up, what we’ll do is we’ll do a trabeculectomy, to see if that will buy us some time until we see if the trabeculotomy worked. And so usually when we do it, we’re doing it not with antimetabolites, and we’re pretty much expecting that the trabeculectomy, the bleb, is going to fail. And it’s kind of a temporizing measure. So yes, rarely. Probably less than 1% of the time that I do a trabeculotomy will I add trabeculectomy. What is the chance to have the cup reversed to normal? But there is subtle damage at the microscopic level? I think there’s probably a pretty good chance. We talk about — oh, the nerve is regressing and it looks normal again. But that doesn’t tell us anything about the nerve fiber layer and axon damage. There almost certainly is some damage. And it is not until someone can do a visual field test, or you can do an OCT and measure their nerve fiber layer, that we know the answer to that. Unquestionably. When I say the nerve regresses, I’m not pretending that everything just goes hunky-dory back to normal. I think there’s some damage there. But we don’t see that nerve cup regress in adults ever. Right? That’s my point. The optic nerve can — cup to disc ratio can regress. That doesn’t mean that the nerve fibers are coming back. Is there a stepwise protocol for exam under anesthesia? A little bit. Let me direct you towards — excuse me — if you go to the Cybersight library, maybe I can do that right now — let me just — since — let’s go to the library right now, so I can show you where this stuff is. All right? Let me go to my desktop. All right. Here we go. Cybersight. First of all, if you go just to the library, if we go to the library, we can look up lectures, surgical videos, so say we want to see lectures, surgical videos, let me uncheck this. We want pediatric ophthalmology. And glaucoma. So if you put those in, in the videos, you can find trabeculotomy. Right? So that’s a trabeculotomy video. But what else have we got? I’m gonna go to textbooks and manuals. And this is the one that I want. Assessing and treating glaucoma in children of the developing world. All right. So this is an older book. I helped write this probably 15 years ago. But it was written by some people that know what they’re doing. And if you go to this, you can either view it online, or you can download it, but in here, let’s see if I can get to the table of contents… Right here. Okay. Examination under anesthesia. If you go here, basically step by step — right here. There’s your protocol. Seven steps in the conduct of an examination under anesthesia. Let me just refer you to that. And you’ll be golden. Because the other thing that I want to show everybody is if you go to the — what about the courses? So — courses here. Because a lot of the stuff we’re talking about — you can actually study at your own pace. And it’s the same material. So catalog. Right? Go to catalog. And we want pediatric ophthalmology. And you’ll find this in two places. So here’s pediatric glaucoma. Right there. As a free-standing course. Fundamentals of pediatric glaucoma module. So that covers a lot of what we just covered, plus some of the stuff we didn’t get to today. So it’s located today. It’s also located within the fundamentals of pediatric ophthalmology full course. All right? So if we go to that, now, that takes you into the full course. Which is strabismus. Basic strabismus. Pediatric cataract. Advanced strabismus. And then module number five here is pediatric glaucoma. All right? So that’s another resource for you to consider. Let me get my question list. Here it is. All right. So that’s the EUA. I’ve answered that one. Okay. Interesting question. How do you measure pressure of patients with a Boston Kpro? Well, I do have one patient with a Boston Kpro, and it is difficult. It’s a tough one. There’s not much you can do. I actually measure as best I can off to the side of the Kpro on the cornea, but usually in these cases, the cornea is opaque. And scarred, and it’s not accurate. Someone was asking about finger palpation pressure. I actually use that sometimes in these Boston Kpro patients. I measure the pressure of the eye that doesn’t have a Kpro, and I feel both sides either with my fingers, or with a couple Stevens tenotomy hooks. It’s such a common pressure problem that so many places, if they’re putting a Kpro in, they also put in a tube shunt and they do a vitrectomy. It’s a tough situation. You do the best you can. What is the cutoff age to prescribe alpha 2 agonist to prevent penetration through the beta blocker? Alphagan, brimonidine. The cutoff for me is around age 5. I try not to use it in anyone younger than age 5. But really, again, it’s not so much the age as it is the weight. If you have someone who is quite small, even if they’re 10, you might want to be real careful about that. I think in any child that I used it in, I would want punctal occlusion, and I would want the parents to monitor the first few doses. Monitor the child. Make sure they didn’t have this CNS depression. So almost never do I use it in a child under 5. And I use it cautiously in older children or smaller children. Is a ROCK inhibitor not an option? It is an option. I mentioned it earlier. It is definitely an option. Do I have any personal experience with it? Very little. It’s mostly just from colleagues that have told me what their experience was. If anyone has had great experience with it, I would love to hear from you. But I have not used them yet. Do younger children need lower concentrations of IOP lowering drops? Any guides regarding choice of drop concentration according to age? Well, intuitively, you would think yes, they do need lower concentrations. When you think about an infant with glaucoma, you’re gonna give that infant a beta blocker, which is the same dose that you’re going to give a 60-year-old, 100 kilo patient. Well, they probably don’t need the same dose. And we don’t know what the minimum effective dose is. But any time I have the option in a younger child of using the lower concentrations, I do. And any time I can pick something that has less systemic side effects, like Betoptic, betaxolol, one of the selective ones, versus a non-selective beta blocker, I do that. I think we always have to keep that in mind. Do I have anything formulated special? Like special order from the pharmacy, at a lower dose, like we do with Avastin? No. I’m using the same drops, but I’m using the lowest concentration with punctal occlusion and as cautiously as possible. How frequently do you use oral acetazolamide? Not too frequently. It’s usually a temporizing measure for me, until I get someone to surgery. But I will use it, and I do have some patients who take it chronically. I don’t think it’s ideal. But sometimes that’s what we do. But it is definitely the last thing that I do in terms of choosing medications. Is to go the oral acetazolamide route. I’ve never had any problems with it. I just think taking an oral medication forever is maybe not the best deal. What about OCT? How old do you have to use to order it? What is the frequency you order it? Are the parameters reliable? Again, super variable. If the child can sit there and get a photograph, they can probably get an OCT done. We will order ones about once a year, if they can do one, that is usually roughly school-aged and older, that can cooperate with that. Are the parameters reliable? I don’t know. Okay? But it is another tool, just like the fundus photograph that you can follow over time. Just like a visual field. A lot of these visual fields that we get are not reliable, and you can say: Okay, that’s garbage. But if you get to the point where it’s reproducible, I think it’s helpful. Here’s a comment. Simbrinza is a very good drug. I’ve heard that. I haven’t used it yet. But good to hear that someone likes it. Here’s another comment. Simbrinza causes a lot of redness in older children and adults. I like Cosopt. Brimonidine, yes, does tend to cause a lot of redness. How long is it safe to keep infants on Diamox? What is the dose? What are the instructions for the family? The dose I don’t remember offhand. But it’s weight-specific, and that should be easy to find. It’s based on a per-kilogram weight basis. How long is it safe to keep them on it? I don’t know. If you’re gonna keep someone on it for a long time, you should probably monitor electrolytes. Most of my patients are on it for such a short period of time, we don’t do electrolyte monitoring, but if you’re gonna keep someone on Diamox for weeks or months, I would keep that in mind. Instructions for the family — usually when I use oral Diamox, my instructions, whether it’s for pseudotumor cerebri or for this, my instructions are warning them about the side effects. It’s a diuretic. You’re gonna get tingling around your mouth, food is gonna taste funny, your fingers can tingle. But fortunately, acetazolamide, Diamox, has a pretty wide therapeutic range. So the incidence of side effects is quite low. Yeah. You just have to be careful about the electrolytes and the dehydration. Do you commonly use prostaglandin analogs in children? Well, I’ll take that back — yeah. Kind of in these older kids that may have aphakic, pseudophakic glaucoma. I not too uncommonly use it in them. Again, not super impressed with it in the pediatric population. The downsides are pretty low, and if it helps some, it’s worth a try. Super expensive still for us. That’s one of the negatives. What is the role of medication in treatment because the angle is abnormal? If you have angle abnormalities, the medications are secondary. If you have angle abnormalities, you need to do surgery until that is corrected. And until it’s corrected, you use medications. So before surgery, you use medications. You have your angle surgery. If the pressure still is too high, you either supplement that with medication use, or you use medications until you do more surgery. So it can go a variety of ways. But usually if angle abnormalities are there, surgery is a priority. The medications are secondary supplements. Would you use timolol, Timoptic, for infants? Yes, I would. If I get 0.25, I would do that. And I would do punctal occlusion. But we keep talking about beta 1 selective. Betaxolol. And using the lowest dose. Even though I think these are all reasonable precautions, I have never actually had any problems using a beta blocker in an infant. Okay? It can happen, and I don’t want it to happen, so we take some precautions. To what age do you avoid brimonidine in your practice? Until 4 or 5, definitely. What is the minimum concentration beta blocker available in everyday practice? What if? That’s fine. If you don’t have 0.25, I think it’s fine. I use a half percent all the time. I’ve never had a problem. Again, same basic precautions. What about dorzolamide for children less than 5 years of age? Yes. I don’t have any problems using topical carbonic anhydrase inhibitors in younger children. Especially the common ones with timolol. I love that. So no problem. I don’t see any issues using dorzolamide in children less than 5. Other than — kids just complain that it burns. Right? Do you give oral acetazolamide to infants? What is the dose? Yes, I use it. And no, I don’t remember the dose. I use it so infrequently in infants that I look it up every time that I use it, but it’s well published, easy to find. Antiglaucoma drops for children with asthma. All right. So this comes back to our avoiding beta blockers when possible. Or if you’re going to use a beta blocker in a child with asthma, it would be better to use a beta 1 selective, like betaxolol. But probably the best thing to do if you have a child with asthma is just not use a beta blocker. Go on to one of the others. Do you monitor the renal function while prescribing Diamox? And if yes, how frequently? No, I do not. Some people will. And I see it being recommended sometimes. I never do it. We have kids on Diamox chronically for pseudotumor, papilledema, and they never have any problems. So for me, I don’t do it. I wouldn’t tell everyone to do it that way. But I’ve never had a problem using chronic Diamox. And some of these kids, it’s not just a milligram per kilogram. That’s usually what I’m using in these kids. Now, if you get into superdoses, I probably would. Because I sometimes see rheumatology — not rheumatology. Neurology using doses that might be 2, 3, or 4 milligrams per kilogram. And I think if I was doing that, I definitely would be a little more conscious about measuring electrolytes. Here’s someone saying they usually give dorzolamide as a first drop. I think it’s a good choice. I don’t use it as frequently by itself, but I think it would be a great first line choice, because the side effect profile is so low. So yeah, I agree. I think that’s a good choice. Here’s a question. May I ask what the prognosis of glaucoma from a practical perspective is? Easy for me to say. It depends. Glaucoma present at birth doesn’t do as well. No question. If glaucoma onset is later after birth, they usually do quite well. They can be 100% normal. You get a kid that’s got ground glass corneas, and they have a goniotomy, and I’ve followed a lot of these kids for 20 years now. Their vision is perfect, 20/20. All right? What gets you into trouble usually with these kids is not so much the optic nerve damage. What gets you into trouble with the visual outcomes is usually the amblyopia from the corneal scarring. So if you have a lot of corneal scarring and a lot of corneal opacification as a young infant, it’s just like having a cataract. You’ll get nystagmus and irreversible amblyopia. That’s where most of the vision loss actually comes from, with congenital glaucoma. So if you can limit the scarring, and the opacity, they usually do quite well. Do you usually take an intraocular pressure at the start of surgery, or minus some amount? Usually take the intraocular pressure as soon as they do mask induction. And then I repeat that after the airway is secured, and then I don’t do it anymore. But I’ll usually record those two numbers. Right away, with mask induction, and then as soon as the LMA or ET tube is placed. In eyes with a widely stretched limbus, how do you decide the scleral flap length in performing trabeculotomy or trabeculectomy, either one? I usually do 4 millimeter triangles. But if I had a really stretched sclera, I would probably do it longer. I can’t say that I have a formula for that. But 4 millimeters on a side is usually pretty good. I wouldn’t make it much longer than that. I can’t see needing anything more than 5 millimeters. My concern, if you get too long of a flap in a really buphthalmic eye, is that it’s a really thin eye, and you potentially could be back over pars plana, conceivably even retina, and definitely over the ciliary body, as you get a really big flap. So yeah, I tend to stick pretty well close to a 4 millimeter triangular flap. There might be some advantage to doing that flap square, though. And the reason is: If you have a triangle flap, and your one cut in the middle doesn’t work out, and you want to do a new one, you don’t have much space to do it. If you do a square flap or rectangular flap, you do one radial incision off to the side, if that doesn’t work out, then you have room to do another one over here. I think if you’re just learning to do trabeculotomy, having a wider scleral flap is probably a good idea. Here’s someone saying: We don’t have oral acetazolamide. Is there a dilution we can do with the tablets? Yeah, they can be crushed up. But I’m not gonna give you advice on that. I would talk to your hospital pharmacist. I’m sure they can figure that out. But oral — it’s just a matter of getting them crushed up. And then delivered in some other fashion. Why not latanoprost as a first line in kids? Mostly because my experience with it is that it has not been very effective. It’s a great drop, I love it, and I do use it. I’m just not very impressed with the intraocular pressure response to it, compared to things like beta blockers or carbonic anhydrase inhibitors. Or alpha agonists. So it works. It just doesn’t work as well. I think one of the great things — I mentioned that the prostaglandin combination agents, prostaglandin plus timolol beta blocker — that those are not available in the United States. I would love to use those. But here’s one of the issues. I was just thinking about this the other day. In the United States, a drug — when you have a combination drug, the companies have to prove that the combination is at least as effective as the single agent, and they like to see that it’s more effective than the single agent. And if not, they don’t approve the combination. But apparently that’s been the case. That the combination of prostaglandin plus a beta blocker is not really that much more effective. Each one individually. And maybe not more effective than one alone. So I think there’s some interesting data out there that we aren’t quite clear on yet. Do you plan EUA and necessary surgery at the same sitting to prevent repeat general anesthesia? Yes. I don’t like to do an EUA in one setting and then come back and do surgery in another setting. We always — it makes it hard to schedule glaucoma EUAs, because you never know if there’s going to be a surgery or not. Unless there’s some extenuating circumstance, we always plan to do both at the same time. We prep the families ahead of time that if we’re going to do a surgery, we’ll come out and tell them after we do the EUA, but I think it makes sense just to do it all at one setting. But we don’t always do it that way. Sometimes there are extenuating circumstances. You do an EUA and say okay, we’re gonna come back in a couple weeks and do this. Handheld OCT. Interesting concept. I think it has some utility. We don’t have one. I haven’t used one. I don’t have a good answer for you. Is any alternative therapy beneficial in narrow angle glaucoma as your experience? Alternative therapy? I think you must be talking about non-surgical and non-prescription medication. I’ve certainly had some teenagers ask me if smoking marijuana would help their pressure. But I think that’s been a little bit debunked. It’s not shown to be incredibly effective. I’m not aware of any homeopathic alternative therapies that have been useful, no. What’s the maximum eye drops you use before surgery decision? Yeah. So for me, when I say someone is on maximum medical therapy, that is usually three drops. And that’s usually two bottles. Maximum medical therapy for me is usually they’re on a combination beta blocker/carbonic anhydrase inhibitor, like Cosopt. So they’re on that. That’s two medicines in one bottle. And then they’re probably on a prostaglandin agent like Xalatan. And three drops, three medicines. To me, that’s maximum medical therapy. I just don’t think that’s sustainable. If someone is requiring that, I usually suggest that we consider surgery. How can we approach a case of PHPV, persistent fetal vasculature, with secondary glaucoma? Well, these are tough ones, because they have angle abnormalities, and they have aphakia. So this group of patients — pretty quick to do tube shunts. Ciliary body destruction with endolaser. You can consider angle surgery. You know, angle surgery — we mostly talk about being for some specific condition like congenital glaucoma. But there are cases that some people will respond to angle surgery, and they don’t have congenital glaucoma. Anterior segment dysgenesis, PHPV, some people do it for Sturge-Weber, even. Some people try it in aniridia. Is it as effective in those situations? No, it’s probably less effective. But you can still do it. Because these are tough patients to deal with. They’re very difficult. All right. Could congenital glaucoma occasionally be controlled on medications alone? So can congenital glaucoma be controlled without surgery? Rarely. I do see some that burns out, or some that might be very mild. These would be kids that have clear corneas. But they have anomalous-looking gonioscopy. And I’ve seen a few of these. It’s not standard that we see that. But it does occasionally happen, that you can control them with medication. I would assume most of them need surgery, though. What is the sequence of investigations for glaucoma when doing examination under anesthesia? I’m gonna skip that, since we talked about going to Cybersight library, where the manual is. Precision of iCare versus Tono-Pen? We talked about that. iCare tends to read 3 millimeters of mercury higher than Tono-Pen or Goldmann applanation. Combining trabeculotomy and trabeculectomy versus trabeculotomy only. We did talk about that. I do it rarely, but only when I think the trabeculotomy didn’t go very well. And I do it to try and get the cornea clear. So that I can either come back and do another trabeculotomy later, or I can do a goniotomy with a clear cornea, but I expect that the trabeculectomy is going to fail. You will not see it stay permanent, unless you use so much antimetabolite that you get a thin avascular bleb that’s probably gonna leak long-term and have a risk of endophthalmitis. Not a big fan of trabeculectomy with antimetabolites in kids. Once eye drops are started, how often to follow up on the patient? Oh, you know, it really depends on how high the pressure is. But if I change an eye drop, or add an eye drop, I will usually see the patient a couple months later. If they have something more serious than that, then I’m gonna handle it differently. But if I am just doing routine — adding a drop, changing a drop, I usually give them two or three months and then reassess. Once a child has had trabeculotomy and trab surgery done at the age of 6 months, baby is now 13 years old, and her vision is 3/60… All right. Child had trab — trabeculotomy and trabeculectomy surgery at age of 6 months. They are now 13 years old and vision is 3/60. With best refraction. The pressure is now less than 20 with Tono-Pen. Is the amblyopia treatment beneficial? And her optic nerve is quite good. Would I do amblyopia treatment in a 13-year-old? No. I think it’s not gonna be effective. Especially if you’ve been doing it all along. Now, if it was a new diagnosis of amblyopia, I will sometimes treat in older kids, but I think it’s very unlikely to be helpful here. And there’s still 300 of you on here. We still have 110 questions open. We are now on 2 hours and 40 minutes. I am going to go for another 20 minutes. And then I’m going to bring us to an end, just because I’m probably gonna need to go to the bathroom or get something to eat or drink at some point, or I will die. But wow. We’re gonna have to do this again. Maybe we’ll just do a question and answer session on pediatric glaucoma. Because you guys are rocking it here. All right. Let’s keep going through these. I’m amazed. Could light sensitivity be a sign for pseudophakic glaucoma in children? Probably depends on their age and how high the pressure is. Younger children, more likely to get high pressures, perhaps. Okay. If the pressure is high enough that they get corneal edema, then they’ll get light sensitivity. That’s where the light sensitivity comes from. The corneal epithelium gets disrupted by the fluid coming through the endothelium, and they get breaks in the epithelium, and that’s where they get light sensitivity. So it just depends on how high the pressure is, and how well the cornea is tolerating it. Do you routinely use medications in some of your patients, or as adjuncts, while awaiting surgery? Yes. Most of my glaucoma patients are either on adjunctive drops or, if they’re waiting to get surgery, they’re on drops to kind of mitigate things until then. Definitely yes. But a lot of times, once you have a successful surgery, they don’t need drops anymore. You definitely see that happen. Where should we give anesthesia? I’m not sure I follow the question 100%. But we do anesthesia only in the operating room at my institution. Some people do sedations in the clinic to do examinations under anesthesia, but you just need to have adequate monitoring and trained personnel. What is the reason of developing glaucoma in pediatric patients if we operate on them for congenital cataract within a month of life? There’s a lot of misunderstanding about glaucoma and congenital cataracts and intraocular lens implants. All right? Now, if you look at all kids with cataracts who have surgery, I think the estimate is somewhere around 20%. If you looked at the infant aphakia treatment study. These kids were followed over time. I think about 20% of those kids developed glaucoma that required treatment. Some people say that intraocular lenses are protective against glaucoma. Well, that has turned out to be not true. The infant aphakia treatment study showed no difference in glaucoma between the intraocular lens and the aphakia group. The reason that people say that is because the ones who frequently don’t get intraocular lenses are smaller eyes. Like PHPV. Persistent fetal vasculature. PFV. You have a smaller eye like that, they have a higher risk of glaucoma, because it’s a small, abnormal eye. It has nothing to do with the lens implant. They just didn’t get a lens implant, because it was a small eye. So there is no protective benefit to an intraocular lens. And why does anyone get aphakic/pseudophakic glaucoma? Well, I don’t think we know. That’s an element that’s still poorly understood. Is it vitreous components that get in and plug the trabecular meshwork? Is it surgical inflammation? You know, there are lots of things that we talk about. But it definitely happens. And you have to monitor for it. If someone has congenital cataract, we make sure that they get dilated every year, and that they get their pressures measured when possible, because there’s a high risk of secondary glaucoma. And it doesn’t matter how old they are when they have their cataract surgery. Okay? Do you trust the iCare-like machines in order to get IOP in children? Yeah. So the iCare tonometer, I think it works. Again, it tends to measure about 3 millimeters of mercury higher than Goldmann or Tono-Pen. It’s a useful tool, though. Here’s someone who agrees with operating on both eyes at the same session. This is what I usually do. Yeah. Even if you have great anesthesia, there are some good arguments for doing both eyes at the same time. And if you have questionable anesthesia, there’s definitely a good argument for doing it. How do you do it? You do it as two separate surgeries. You operate on one eye with a scrub. You do a scrub, a prep, a scrub, a drape, instruments, and a bandage, and you do that first eye. Then you take everything off. You prep the other side. You treat it as two — and you use a different set of instruments. And different gown and gloves. And if you do that, that should be totally safe from an infection standpoint. Now, if you’re having to use the same instruments and the same scrub and prep and all that stuff on both eyes, is there an increased risk of endophthalmitis? Well, if it happens, you’re gonna have a problem. But it still may be warranted, if the anesthesia is dangerous in your location. So everything has to be taken into consideration when you make that decision. And there’s no right or wrong answer. You just need to be able to justify why you need to do it that way. What about iCare tonometer? If you said something, I missed it. I find it very easy in clinical practice. Thank you. Yes. I love the iCare tonometer. It is a very good tool. However, it does tend to measure a little bit higher than the Tono-Pen or Goldmann tonometer. About 3 millimeters of mercury higher. So if someone has a normal pressure with an iCare, they are good. If someone has an elevated pressure with iCare, I may suspect that it’s over-reading, and I will recheck it with either Tono-Pen or Goldmann, to see if it’s actually lower than that. I have had little or no improvement with medications. Please, what’s your experience? For primary congenital glaucoma, the medications aren’t going to work. Okay? You can think of it as like a bathtub. In primary congenital glaucoma, aqueous is coming in from the water spout and filling that bathtub up. If the drain of the bathtub is closed or blocked, it doesn’t matter how low you turn down the water flow. At some point, that bathtub overflows. You have to open the drain. You can’t turn the aqueous production off enough to offset lack of outflow. So medicines are typically adjunctive, secondary treatments. Would you use Iridex on a child? Yes. So Iridex, micropulse, G-probe, endolaser. I routinely use them on children. Probably not my first line surgical treatment, but I use it when I’m having trouble controlling refractory cases in one of those three formats. If you don’t do bilateral surgery, how soon would you schedule the second eye? A couple ways to go about that. Sometimes if something was really urgent we would do one eye on a Tuesday and do the second eye on Thursday. If the urgency was less, I might do one eye one week and do the second eye a week or two later. When I knew that the first eye didn’t have endophthalmitis. So different urgencies, depending on the status of that particular patient. This one says: There is a randomized double masked multicenter study to compare latanoprost versus timolol. IOP reduction was better with latanoprost. What’s your opinion? Okay. So here they’re saying it’s a randomized, double masked, multicenter study comparing latanoprost versus timolol, and that the latanoprost group did better. What’s your opinion? I guess my first — I wouldn’t be surprised if that was true in adults. I would be surprised if that was true in children. And I would be particularly surprised if that was true in young children. So I guess I would have to look at that study to give you an opinion. Just because medicines might work one way in adults doesn’t mean that they have the same degree of efficacy in children. And it’s hard to do randomized studies in children. So a lot of that stuff’s not — we have some safety data. But a lot of times, we don’t have efficacy data in pediatric drug studies. Which surgical procedure do you do mostly? Goniotomy, trabeculotomy with trabeculectomy, and… Oh. Goniotomy or trabeculectomy or trab with trab? Most commonly, I do trabeculotomy. And I most commonly try to do it as my first procedure for 360 degrees. Because if that works, I have the entire angle open. If it doesn’t work, I do something else. But it also depends on the clarity of the cornea. If I have a really clear cornea, I may start with goniotomy instead. But trabeculotomy, especially 360 trabeculotomy, is my go-to number one procedure as a primary procedure. And the reason for that also: You don’t want to try a 360 trabeculotomy if they’ve had any angle surgery before. Because there’ll be scarring in those channels, and you remember I showed that picture of how the suture, the prolene suture, had left Schlemm’s canal. That was on someone that had already had angle surgery. It probably wasn’t a very good decision on my part. I probably should only have done that on someone as a primary procedure. In VKC, intraocular pressure is not higher, but it’s borderline. Which medication is better? Borderline pressures? I don’t know. I think you can pick whatever you want. If someone had a borderline pressure and I wanted to put them on a medication, I would do something with a very good safety profile. Again, we’ve been talking about prostaglandin analogs. Someone with a borderline pressure, I think a prostaglandin analog would be a great first choice, unless they had uveitis. I do deep sclerectomy for primary congenital glaucoma, and the results are excellent. So there’s a vote for deep sclerectomy. I have not tried it. But there are always other things out there, and we can always learn from each other. Do you use antimetabolites? Not anymore. When I was a resident, I trained in trabeculectomies, and we did trabeculectomies with antimetabolites. When I started as a pediatric ophthalmologist, we were still doing trabeculectomies with antimetabolites. And that was about 23 years ago. And about 5 years in the practice, myself and my senior partners, we all just decided that it wasn’t working. When it did work, we were having bleb leaks. And we were having endophthalmitis cases. So I have a group of seven pediatric ophthalmologists now. Maybe eight. And none of us continue to use antimetabolites. None of us do trabeculectomies anymore. So your experience may be different, but we were not impressed. I can’t find probes for trabeculotomy from Duckworth-Kent. Any recommendation for a sharp and delicate one? I can look into that. I don’t know where ours come from, quite honestly. But I can find out and see if we can get an answer for you. Which surgery is most effective for young children? Trabeculotomy or trabeculectomy? I think it depends on if they have congenital glaucoma or don’t have congenital glaucoma. If they have congenital glaucoma and they are young, a trabeculotomy, opening the angle, for 120 or more degrees, would be my preference there. Trabeculectomy in a young child is probably gonna be a temporizing measure. It’s probably going to fail. Why not open the entire angle, three trabeculotomy sites at once, instead of three consecutive additional procedures, since most often they will be necessary? You can try. What you find when you’re doing trabeculotomy is that it gets increasingly difficult, because you are lowering the pressure of the eye. So, for instance, if you’re using a Harms trabeculotome, and you open the angle to the left, and then you try to do the angle to the right, that second side is always more difficult. So now you’re saying: Well, I’m gonna do that. Close that up. Move to another site. Do another cut-down on a soft eye. And find Schlemm’s canal and do another procedure there. I don’t recommend it. If you can do it, good for you. But trying to do that on a soft eye that you just decompressed — I think you’re gonna struggle. Yeah. I think you’re gonna struggle. Which is why the simultaneous 360 with either that suture device we showed or the Microtrack is so appealing. Because you’re just doing one cut-down, and you don’t have to deal with the hypotony. Do you repeat trabeculotomies? If so, what is the time interval between them? How do you decide the time interval? The time interval is usually long enough that the eye has healed. So a couple weeks at least. And that the inflammation has diminished. And any scarring that’s closing off the incision has taken place. And so it’s usually about a month to six weeks. I would say that that’s pretty common. But a lot of times you’re treating both eyes. You might do one eye, then you’re looking at the other eye a couple weeks later. So there’s some variability to that. But if I’m just dealing with one eye, I’m probably gonna do a repeat EUA. Possible surgery 4 to 6 weeks later. How readily available are the goniotomy lenses? I’ve found they are quite expensive. Yes. I bet you did. They are expensive, and that’s one of the hindrances. I don’t know a source of someone who makes inexpensive goniotomy lenses. But yeah. That’s the one hurdle with goniotomy. The needle knife is cheap. The lens is expensive. Which gonio lens is preferred for goniotomy? People will have different preferences. Some like the one you suture on. I like the little ones like the Swan-Jacob, Swan-Ganz, with the handle. They come in a right hand and left hand version. I like to be able to put them on and off, and rotate the eye with an assistant. Shall we succeed when we apply the same strategy to detect both childhood glaucoma and adult glaucoma? Well, a little bit of difference in these two, in that young children with glaucoma have obvious signs and symptoms. Whereas adults with glaucoma very rarely have signs and symptoms. And I think that’s what makes it so tough to pick up adult glaucoma. This person — I sit temporally, and do a combined nasal goniotomy. So temporal approach, opening the nasal angle, and temporal trabeculotomy, sparing the superior conjunctiva for possible drainage in the future. All right. So they’re doing a combined goniotomy and temporal trabeculotomy. That seems like a reasonable approach. I also do inferior nasal tubes sometimes as a primary procedure. In case they need possible drainage, such as a bleb, when they get older. Yeah. So that’s one — certainly one combination. Inferior tube shunts. I have had some difficulty with those. Not my preferred location. But I understand your logic with sparing the superior conj for trabeculectomy later. What would be your first choice of surgery for very large buphthalmic eyes, greater than 13 millimeters? If I thought that I could easily do a goniotomy or a trabeculotomy, that would still be my first choice. If I couldn’t see to do a goniotomy, and I felt the eye was so stretched out that doing a trabeculotomy was going to be difficult, I might go straight to a tube shunt in that condition. That would be one time, potentially, where I would go straight to that. You know you’re gonna get the pressure down with the tube shunt. You just don’t know if you’re gonna avoid the other complications that come along with them. Can you use a Kahook dual blade for goniotomy in children? Yeah, I don’t know the answer to that. I have not — I don’t have one. I’ve never used one. I don’t know anyone who uses them, personally. This is a good question also. Would you use Miostat intracameral, before goniotomy? Yes. I did that last week. We didn’t dilate the child, but a lot of these young kids have large pupils to begin with. And we were having a hard time seeing the angle, and so during the surgery, I injected Miochol, Miostat, brought the pupil down, and it helped a lot. All right. I’ve got about two more questions here. We still have 141 unanswered after this. So I apologize if we didn’t get to all of them, but we’re going on three hours now. A lot of you have hung on. We still have 259 participants. So you have my respect here. Please explain more about tilting the patient’s head for goniotomy. Is it away from you? Okay. Yeah. So if I am the patient laying on the table, the surgeon is over here, trying to operate on the nasal angle, I would take the patient’s head and turn it away from the surgeon. So that you’re looking — you get a better angle in towards the trabecular meshwork. So tilt the patient’s head away from you. This is why, when we’re doing goniotomy, we usually like to start from the temporal approach, because it’s easier to get that rotation. Again, you can tilt the microscope too. But you just don’t get as much angle benefit. Okay. How many degrees of angle do you usually open during goniotomy? It’s probably right around 120 degrees. Some of that depends on — if you have an assistant who can rotate the eye while you’re doing it. If you do, you can get larger amounts. If you’re just limited to what you can stick in and sweep without the eye being rotated, you will not get more than 120 degrees. All right. And the last question goes to… Dr. Alobesi. Do you try goniotomy with a cloudy cornea? Because here in KSA we have severe congenital glaucoma. No. If you have even a mildly cloudy cornea, you are going to struggle to do a goniotomy. Once you get the gonio prism on there, and once you have any light from the bright light microscope, you’re not gonna see anything. That’s why I say if you’re going to be good at any one procedure for congenital glaucoma, you want that procedure to be a trabeculotomy. All right? So that’s one of the benefits. You can do it through a cloudy cornea. You can do it through a clear cornea. You can do it in every quadrant, if you can learn to work around the nose. So that is by far the procedure with the most utility. Someone mentioned the cost of gonio prisms too, and how they couldn’t find one they could afford. That’s another good reason. I’m sure that if you look for trabeculotomes, from a US or an Indian or a Chinese manufacturer, you can find some pretty inexpensive trabeculotomes. They’re just little pieces of metal. So I imagine — and once you buy a set of those, you’re good to go forever. They’re not gonna get damaged. They’re not gonna get scratched. And you can do — if you can get two trabeculotomes and learn how to do a trabeculotomy, you can cure congenital glaucoma where you are. Just as simple as that. And that’s why it’s always been my favorite thing to go teach. I can sit there — you can watch the videos, and you can learn to do it. Or an Orbis person can sit there and do it with you. I think it’s basically the same. And you just have to be patient with it. And if you don’t find Schlemm’s canal the first time, do it again. Because if you don’t keep doing it, and you don’t get better at it, and you don’t learn it, that child’s gonna go blind. Right? They’re going to go blind. It’s as simple as that. So don’t be intimidated by trying these things in these desperate cases. It can be done. Okay? All right. You guys are awesome. We still have 250 people. I’m sorry. We have 90 questions still in the queue. We have answered probably close to 200 questions over the past three hours. I am going to cut us off there, and I thank everyone for your participation, and for submitting the questions. Just really some outstanding great stuff. And I look forward to our next session together. Maybe we’ll do a follow-up congenital glaucoma, and just keep after this. Okay? And we’ll get some cataracts and other stuff. I like these question and answer sessions like this. Everyone have a good day. Stay safe out there. Let’s all get back to normal. And thank you.
May 18, 2020